GW1--01665_Well Construction - GW1_20240313

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. WELL,.CONSTRUCTION RECORD . • ••. •
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: :This form can be used forsingle or molgple wells
.•• • 1.Welt Contractor information:. .' : '• - : . : • . • . : . : . . ', •.
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•: 14.WATER ZONES .: . •: I I
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VJoll Coaaa000rName . ( ., . . . . •. ..
• NCWC 2028 A .:: • ::: . .,: • . ..: . .:: t . . 1::; '.-:: ' . .
....NC Well CoceacmrCadfication!lumber lS.OUTERCASING(farmalticaseditelle)ORLIlNERCd )
_' Id20M � TO DIAME'1'F.R.i T'IIICSNFSS . ; MATERGL
• Ferguson's Well.and Pump; LLC Q 5,tr,. � i is P�5,1)/2i
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Compwy.Nama - , '16.INNERCA8ING0 G(aedt�imaldased-1onA) � � .
FROM: TO DIAMETER: 1HICKNE99: MATERIAL
'2.WeII.CousteaedanPerntit# ' . . •• •.•bisbeI . ' 6645-r• . . ' • fL' • -- fr• ` •• ' •',•fic'' • • . .. . . . . .. ' ..
•:List all applicable veil corisbocgonptrrdls AC.County,Siate, i,ance dr).- '
:3.Well•Use(cheeisweHuse):.• .:: .: .:. .: .17.SCREEN.•. . ' . .. • . : . .
Water Supply Walt • ..: . .• _ .
FROM TO DIAMETER SLOT 9ZE 'IffiClaVFSS' MATERIAL
❑Agticulhaal: ft ft: is
• '. �. •'l7 pa]/Publib
• • ❑Geothermal,(Heatingi ooliag.Su ly) . tia1 Water Supply(single). • .• • it ' • . , in • • . ' • • • - • • •
❑Jtidustrial/Commercial. ❑Residential Water Supply(shared)• 18.GROUT_To , . MATERIAL. • EMPLACEMENTMEFHOD4a,hles ;
❑Irrigation . : ..' . . • • - 0.:. . •.is 2i) ft Concrete.. _ Gravity,-Flower .t••�.o .
Non water Suppt9Wel1.:
ol�tonitoring . ❑ltacovery M; . , ft . . . ...MAR 1 '''; 20Z4 . . .
Injection well: ,ft., ft
:❑Aquifer Recharge• • .- • DGroundwaterltemediation - 19 SAND/GRAVEL PACK Of ennoble—) .ik3'7::-- ' :"-.,''_:�:i.)1yf,. .
❑Aquifer Storage.04%%c.oveiy ❑Sarin tyBarrier .' .•• : . FROM TO MATERIAL'•' : • E P' ' ' '''&: • ' '��` •
.'❑Aquifer Test. • •:. . ❑StomlwaterDrainage. - • " •
• . • :ClExperimental Technology : • • ❑Subsidence Control • ' ' • . • ' ' • • ' ' . ii, '
2(1.DRII1.IIIG LOG.(atta&sdditiuoal abeets ifaeatases)
❑Gcuthemulll(Closed Loop) :• • . ❑Traceu' :• FROM•- TO •DEst:Rlprt (whir,bardnes,mWUrede ty ir,elfin die.eta). .
• '❑Geothermal(Heating/Coaling Return) IjOther(explain.undes#21 Remarks). . .•C2,is• .D -IL, : �1 • • '
A.•Date Wells)completed �`/�y Well1D# -//,,
0.
5a.R►eII I;ocatoa: / 7 S'.n. : g.h ��- c2'GcC r l7`+�
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r. •. 5A, , 7J5 ft . s e c . . ' , :
flO f t /\..et 1.. 'ft.,. • •ft' • • • • • • • • •
Faci(itylQwncr!lame. Faoility.lD#'(ifapplieable)•. .
_ 'fL, ft '' •
r i2 .. ��y� a8'�3�� :�: . ft.
Physical Address;City,snit Zip
•' � n,Irvt►tAlrine � ,
. unccwi(ae. . • 9 6 5 ,37•73/ . • • . • . • . ' . • ' ' ' . • •
County �arcelldenbflcaboallo,(PIN) • . •
SG.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: .
22:Certiftcahon:
• .(ifwdll fiord,one letUoag is suifima�) : ' •� �
.-•3. .°30- 7, yl,�1r - .1�..'§ a•ny, /I. 237 '. ' w ( y L. 5 a �,• .
Si . weticonaaef�.
6• •: :.Ia(are)the well(a)::li ermanent `or• .❑Temporary: ' • i; '
B3'sigrring tlds form f herrby cerfy llie weA(s)war(wen)ccnsb actin•to aeeordcmce
• ' '•' " '' with 15ANCAC 02C.0100 or 15ANCAC,02C.0200 Well CoissirucaiaS(mulmds,and that a
•' .•. 7.Is this a repair to an esisdng•well:•• °Yes • or ' Cho• copy of this record has beenpiavichd to the well owner., • -
.'lfthisis a repair fill oulbmwn well corubaction irforthalion cord esplain the native of the , . .: : '
repair under#21r orkssecionorontreebadc•ofthisfoiro. - 23.Sidediagramoradditionalwelldetailae . . • -
- :• : : • • • ' You may use the back of this page'to.provide additional well site clrtails or well - ••.
8.Nnmber of wells constructed: - • /- . ,• construction details.:You may also attach additional pages if necesau).
' •-:- For fyation ornar-walersupply wellsONLYwlth the.some corisbudion,you con B ' • • ' -
sabimionefoms S[JSIIIITTAL`INSTUCTION
' 9.Total well depth below land surface: 7e (ft) 24a. For All Wells Submit this,form.within 30 days of Completion of well • . :. •
:For wells list all depths.rfdif fesent(ixanpk.3®200'arid 2@a!_00') : construction to the following: . . . • ' , •, • •
•• 10.Static water reel below top-of casing.. • '. (ft) Division of Water Quality;Information Processing Unit, •
Jf water Jevel tiabove carts;use"+" .•
.., „ • '1617 Mail Service Center,iLikigh,Nt 27699.1617 •
• • 11.Borehole diameter ;,-. • m. . . 24b.For 7nieelion Wellrs:. In addition to sending the form•to'the address In 24a . . -
: - _ . . . Rota above,:also submit a..copy-of this form within,30 days,of'completion of well : •.
: : 12.Welt construction method: •. ry -• •• •construction to the following. . .
= (i.e.auger.rotary,;cable,direct etc
,• Pam.• ) �, � .• ,.�
• .- -• - Dlvisiohi of Water Qualify,Undergroundgram Injection control Pen ,
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FOR WATER SUPPLY WELLS ONLY: •.' . .. ' . • . • ' •. • • • . • • .1636 Mail Service Center,Rigeiih,NC27699-1636 . • • . '
• • • ..r' •• . Iniedion�Wells:'In addition tosending the form to •
.. 131.Yhdd(bin) • . - . .: •- tad •of test. •Blowing-Rig
Z4m For Water Sub.*&
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the addresses)above, also:submit one:copy of this.form within•30 days of:
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.'• 13b.Dldmtiction type: Chionne •' • 'Amennh•: ' . •1 D •.• •• OZ.• completion of.well construction to'the,county health•department,of.the county . '
•where constructed., .
.FornG W l: - :, -: North Carolinaflcpaznnent of Envuennient and Natural Resources-DivisionofWatdr.Queh , 'RavisedIan.2A13.••• •