GW1--01656_Well Construction - GW1_20240313

.WELL CONSTRUCTION RECORD • •. a'' 1
1'Lis form can x used*single or multiple wells
• For Internal Use ONLY:•
•
•1.Well Coatracter infornioadoa: • • • • • • • • ,
•
Bobby/W. Potts. • 14.WATERZONES_.:• . �:
7 PROM •TO r 'DESCRIPTION • .
• •Wall contratrxame• : • ft.: �. 'f
NCWC 2028=A •
t I.
NCWe1lCoetiaemrCe:tifieetionNnmber ' ,:
' • 15.OTTERCASING(formtil8ame3weDs)ORLINIi f * He)
FROM TO. DIAMETER TIREDNESS •MATERIAL-.
. Ferguson's Welland Pump, LLC n: ' c .ft 40r Tin.. ',MJ . c5p1(M/
CompaoyName ( , 16.D NRRCASINGORTUBING'(Qleo�rm 1&eed-lotm) • ' .
2.*ell Consauetion Permit th.. ,•6JOa a -.b U 3,5 .. PROM R TO ft DER•IL• .THTCKl�IIt4•• •MATERIAL .
Lts(all applicable well eambueaonps.ra its ge..Cormty,StareYorimhce etc) ft • .
3.Well UM(cheelcwell used . • .
. . ..
water SuPPI9 wed . . FROM: TO DIAMETFli SLOT S2E TRTt�IL*59 blATERiAL
OAgricnitival' ' C�pal/Pub]ic . . _ . . . .
• ft •ft . ' m
•
• OGeothesmal.(Heating(Cooling�Pply) • • 'fiat Water Supply(ogle) ' •-ft' - ' • m:.• . • • •
• Oladustrial/rrn,,;lerci•Al . :, ', OResideatial Water Sunnly(shared) . WI7T : _ •
FROM TO MATERIAL• •FMPI tCF.l1Sffi�1T Mir1EODaAMomft
: • olaigatioa • • . . . • 0 ..ft 20 • . ft Concrete-. Gravity,.Flow ,;' ' .;
Non-water Snpply.Wdi. 4r t.'"; a/; t '
ft ft
• . 'OMonitoring • • . • • ' .oRecovcay • •
' .
• . :Injection Well: • . • . . f . ft • � . _�.Z� .1
•
°Aquifer Recharge• .1]Gro mdwater Remediation•• • • 19.SAND/GRAVEL PACK(fd e) �� •• • .
•DAqu• fer.Storage and Recovery: O Salinity Barrier : FROM ' • TO ft: •MATERIAL 3 EtV LACEhdP1�L dMETt30D iSU •
•
OAgtlifer Test. OStormwatet Drainage
ClExperimental Technology ' . [)Subsidence Control . • . • " '" ' ?:
•
?A.D1Ln•T• GLOG.(at�adilddoalalreensifnmesus) .
• 'OGeuthtainal(Closed Loop) OTraccr .• : ' PROM TO • •DESCR�ITON solar,tardnrs,con/rock type,elate she,etc) •
OGeotheimal(Heatiug/Cooliag Return) •OOther(explain under#21 Resnadcs). .. a . . . . . '. , . . . ..•� f ' Clay
.4.Date Well(s)Completed:/ ' •Well ID# �� SQ'4[rJ f' d Q-
sa. •weu .ocatian: ' . �7` . . . . • . -' .• Atpe/je(-/C- . .d
.
• �S. �f1Gz r�'r
f ta.-, ••Mir-fr(( . • . . . .ft - . .f`. . . . . .
• Facility/0waorName • • " . • FacrlitylI)#(if applicable) • • -
•60 QQ r• , I�'�
'Nl q , UirI aYc 'i' ts` �'�k,Qi)na.lp40 ' .ft: •. . ft,
Physical Address,City;and Zip`
lAn(/Shrrlh e Cj 4 B7 44053. •
County Parcel Idendfca6onNo.(PIN)
Sb.Latitude and Longitude in degreeshninntes/seconds or decimal degrees: • . • •
•
(if*r fl field,one liVloag is.sui icient) . . • 22.Cert�cation.
- _.: S 5v s.7..ti$.- c/.lv"53"-2, /7, 14' . w .. • / ' .:
i red �c� .
� Shgnature ofce WoD.connmxor,•
6.Is(are)the well(:)::C4Permaneat ••or !]Temporary • • ' • • .• • :•By aigrnng this form;I hereby con that the well(s)was(were)'conslructed:in accordance - '
• with 15A NCAC 02C.0100 or 15A'NCAC 02C.0200 Well ConoructicnStanulmds and tot a
• 7.Is this a repair to an'e=isting•evell:. Cl • or .' u • ' . .• •• . . copy ofthis record has been provickd to the Well Owner...• • . . . .• - ' . . •
C#N '
•:jj&lsis amid'',fill out b,own well conitniction infwinalion andeaplain the nohow often I • , .
' repetrmrder#21r ssalionorontiebadr.ofthisfomr. 23.Sitediagramoradditionalwelldefails •
• ' ;Yon may use the back of this page:to.provide additional well site details or well
S.Number of Weill contracted: ' / . - • • construction details.:You may also attach additional pages if necessary. • "
ForriallipkWeoharemon-waserauppJy wilk 01VLYwith the same earstrireliah,yan can'• .
subru i arrafmmr' :SUBMITTAL INSTUCTLONS , ' . .a • . . ' . . - • •
• 9:Total well depth below land surfaces • /YS•• • • ' (ft) 24a. For'AR Wells: Submit this fore,within 30 days of completion of well
' Fornadtple weAsJtrt aU.atep&s.#f eon'(:maple;:3@200'and2@100) - • : • construction to the following
. • . •
10.:Static water level below top'of casing:.• • . 30 • • , •(g) ••• Division of Water Quality,informadon'Processing Unit, ' '
' ,.(jwiaterlevelleaimecinfr. ;use"+ . • . • • •1617 Mail Service Cent;,Releigh,NC27699-1617 • :
. • 11:Borehole diameter:; * . • '• . (m.) 24h Far Infection Walla In addition to;sending the form to'the address'in 24a •
Rota • . .• above,.also.submit a.copy.of die:fom within.30 days.of completion of well .
12.Welf construction method: • ry •• .• 'construction to the follovdng.
.• '' (r.e..auger,'mtary,,eabh{direetps,ec.)•
. .' .• Division of Water Quality;Undergrnmrd Injecdou Control Proving •
• FOR WATER SUPPLY WELLS ONLY; • • • - • • 1636 Mail Service Center,Raleigh,NC 27699-1636 .• • . •
13>a:meld:(gp ,/6 •. • Method ot'test: Blowing-Rig 24e.For Water Sauuiv&Infection Wells:'In addition to.sendng the form to . " . •.
.•• , ., . • .•. . .• the•addresses)•above, also submit one copy of this.form within.30 days of.
13h DisInfe •dion typ•e Chlorine : ••Amolmt: oZ.• • conipletion•o f Well Construction'to-the county health department.of the county • '
ere constructed.,
Form(slit/--l. Nor:hCarolinaDapettaientofEnvironmentandNapua!Resources—Division of Water Quality •RevisedJae 2013