GW1--01662_Well Construction - GW1_20240313

• • • •
WELL CONSTRUCTION RECORD : •For lattrnal test •ONLY: : i .
This form can be used forsingle or multiple wells
•1.Well Cont actor Information: • - . : "
Bobby •: 14.WATERZONES .:• .
PROM. TO r DF3CRIPFION
:.Well ContradorName' • d© ft.. "
fc: •
: . ., NCWC 2028-A : '
• • • • 15.OUTS.RCASING(formnldcaxdwills)ORLlNER6dai Unik) • '
NC Well ConQnetarC•estifiwtionNumber . .• .
• Ferguson's Well.and Pump, LLC " (�" : 70. it •, S'" . 2/ 0 c.,PdZl •
CompanyNamo 16.INNERCASINGORTURING(aeatBamaIdm d4oOD) " .
2.Weil Construction Pernnt#••. " " 2U2'3•-" -66 Oet
• FRoaa.i; T fft. Dzu�1LrR TSI "' O CJ ME 5' MATERIAL
list all applicable Wei casrhuedon poridts(La"Cotorry,State,Vartance,etc.) 1
3.Well Use(chedtwell use)e • .17.SCREE .• . •
N. , . . . . . . : •.
. . Water Supply'Well: . : • . . . " . .. FROM:• To. DIAMETER SLOT SIZE -TRICZNE - MATERIAL . ' ,
OAgticultutal' �. DMummic'pal/Pubhc ft ft m . .
• OGeothamal.(Hcating/Cooling may) J es•idential Water Supply(single). " •• •" • - m'; '
Olndustnal/Commerr+ial.. . • OResidential Water Su • is.GROOT • • • : . " :I : "
• • • . PPly( PROM.' : "TO '. MATERIAL: FAcPLACFMENTMEIHOD&AMOUNT.
Olrngataa : . . .' . • . •
Non-WaterSupplyWeLL G • �` 20 ConCPete Grd2iiiy-F{Ow,. • •
OMonitoti tg DRecovery rc �.' ...r��ii k. c`j )
;Injection Well: . • • fc ft ' • MAP, I" ;, 20 o 4•
-OAquiferRecharge-, . oGtouadwaterRemediatiou"'" ' 19.SAND/GRAVEL.PACK fdauniksde) . • tT .
• • • FROM: TO :MATERIAL Fl1�LACFd4ffirL!'METHOD.'
•['kilter Storage and Recovery'. ' : ." DSalmity Balkan : " ' ' . • ' .•. Y ram;c`n�.
OAquifer Test. • . • . " OStomawater Drainage
• OExperimental Technology " . OSubsidencc Control " . .' - . . • . •
TA.DRILLING LOG.(attacL adSl@doal theetaif'..' yl
" • 'OGeu ietinal(ClosedLoop) OTraucr . PROM" TO .DESLIOP lON(color,hardness,sdlhock ape,Ruth die,etc) . -
• OGeothennal(Heatiog/Caolmg Return) • DOther(explain.underll2l Rema&s). 0"fa •ft i • • • .•' •
• " - ' ' • . • . " . ' . • • • Q•.ft" 770••.ft . • � .Sili?'1.�S -
• .4.Date Well(i)Completed• ,f ���3 •:•
wall •ID#
Sa.Well•Lottition:. •' . . 70 f<. 75...f
! • ,,e' ��C: . . •
: . . ; . 2 ft C�r�l Lt>j r/4-
Faai(itylQwnc Name . " -- ' - Faciity.I�D#((ifapplieabla) I' " ' • , - - . '• -
S�':Spr i 11 l�(7UQ, Q'tsia-� 7 1:W i IC}/:�SUI�Io . fe: ' 'ft• _ ' •: ,i. • _
Physical Address,City.and Zip" A€7ai121.REMARK• • ' •
) n.eni\bp. • •g71^i(454(01)63 .' • • . . . . .
County P•arnel Idenbflcanon
Sb.Latitude and Longitude is degreeshminuiea/aeconds or decimal degrees:
•• (ifwell 444 onalatMirg is suidciFit) : 22.:Certidication:. . I " .
,• . j s'W S y; 0Q2 N' Zs�:`1;3.764 0 geq " w. .r ' 1'1 1<4L A -/
• • . " . :Si ,of C *Well Contractor , . " ,
:6.Is(are)the weil(s):•wrerivanmt• "or'.OTemporary: gy fining this form,l herby cest{�!that the wails)•• ••••.•• ere)'eaistn,ried ut aeeoni<mce • •'•
" with 75A NCAC 02C.0100 or ISA NCAC 02C.0200 Well.Con iruettooStaedard.and that a
7.is this a repair to aisting•welL••- DYes• or • [liTo of copy ees record been prwtekd to the weltowrur.. . • . . ."n•ex •
• Ifthisis a repair,fill ad known well construction information aod explain the nature ofthe "• • . ' - . • . . ' .
repair.raider#21 rana kssection or onthe backofthisform. • 23.Site diagram or additional well details. •
. : " : • You paying the back of this page:to.provide additional well site details or well ' ,
S.Number of wells constructci: ' • '• / constmction details.:You may also attach additional pages if nece: •
• Fornmliipk hajeotiaiornors-watersupply wells ONLY with the setae consfradion,you coo•• " . •
subndt arefonra S1JB IITTAI:INSTUCITON3
. 9:Total wen depth belowland'surfai e: • I • ( )" 242. For All Wells: Submit'this,form_within 30 days of'completion'of well •
. ' , For mrrbiple rrellrhSt all.deptkre ffdfjervut camp* .00'and 2@100) . ' . . . . . ' :construction to the following: . : .
10 Stater water l el6dow top of ca g:. '" . CIO (g) . • • Dmsion"of Water'Quality,Information Pr+ocesdmgUnit,
• '' 1f waterkvel flabatu casts use"+"" - 1617 Mal Service Center,Raleigh;NC 27699-1617 -
• •11 Borehole diameter. - (n.)' . • 24b.For Injection Wean In addition
to sending the form to the address in 24a .
ROta above, also submit a copy.of this:foim within.30 days of.compleetion of well •
12.,Well conduction method: •ry : amstruction to the following: . : . :
(i.c.auge,rotary,'cable,direct push,cte.)
Division of Water"Qu Undogrntad jnectiast Control Poeo ality, �r J gram, •• " FOR WATER SUPPLY WELLS ONLY:•. • ' . • ' "• ' • " . ' " ' " ' 1636 Mail Service Center,Raleigh,NC 276994636. • •
13a:Yield(gpm) ".- y" • Method ot'tesk. Blowing-Rig :7.4C.For Water SnpDi9&Iniection.wells:•In addition to sending the fomt.to .
. . . . • . .• • 'the•address(es):above, also:submit one copy of this.form within 30 days of.'
• 13h Disinfection type: Chlorine ' Aron •k •. .0z. ... completion off-well cons/motion.to the county health department of the county " .
..where constructed
. ' :feria ow-1: ••, North Carobsa Dcpsrthurnt of Eirvironmcnt and Natural Resources—Division of Water QualitY1 . : Revised Jan.20.13.