GW1--04138_Well Construction - GW1_20240717

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells - •
1.Well Cont m Contractor Inforation: I
•
14.WATER•ZONES
Bobby W. Potts PROM TO e , DESCRIPi:TCN
Well Contmctoi.Name ft. •. - ft
NCWC 2028-A ft. ft .
NC Well Contractor Certification Number 1S.OITTEl'ZCASING(foe mat6.ctmedwens)OR LINER Of applicable)
PROM TO DIAMETER THICKNESS MATERIAL
Ferguson's Well and Pump, LLC 0 ft Q$' ft. ( a,S3 to 2/o,/,2S' /ti(csoif'"'
Company Name • 16.INNER CASING OR TUBING(reodsormal elared-loop)
a75 U a (� >� PROM TO DIAMETER THMENESS MATERIAL
2.Well Construction Permit#: v ft ft in.
List all applicable well catsnttclion permits at.County,Slate,Variance,eta)
-
it ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM To DIAMETER SLAT EMS THICKNESS MATERIAL
QAgricultutal p eical/Public ft ft in. -
❑Geothexmal(Heating/Cooling Supply) L�Aestdcatial Water ft ft in.�PP15'(single) -
❑Indust ial/Commercial ❑Residential Water Supply(shared) 1S.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD a AMOUNT
❑Irngahon 0 ft 20 ft- Concrete Gravity-Flow
Nos water Supply well: • ft. ft
❑Monitoring ❑Recovery
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Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Rcmediation 19.SAND/GRAVEL PACK St'midial4 I
❑Aquifear Storage and Recovery ❑Salinity Barrier PROM TO MATERIAL_ EMPLACEMENT METHOD
f. ft. • .
❑Aquifer Test ❑StomiwaterDrainage ft. ft
❑Fxperimeatal Technology ❑Subsidence Control 2o.DRILLING LOG.(attadt additional a if necessary)
A
❑Geothermal(Closed Loop) ❑Tracer PROM TO DESCSIIPTION(color,hardness,soWtock typ_y crate slu,des)
❑Geothermal(Heating/Cooling Return)1 ❑Other(explain under#21 Ranarks) ( it 7-0 ft I�(4 t/
4.Date Wells)Completed: Well ID# ?() ft 0 ft say er
/ / ge'/ f` �l q f C/
it- ft. (,
MV{ M5a.Well .rl'-i L( .0 11�ft 7105 ft � cu.•,
Facility/OwnerName Facility rim(if applicable) ft ft ,A•r L,.�- VI 1.:D
as 22 cij t n 7ra5�t,tr.e Or d u FTj itir ea S 730- ft. ft :IA 1 7 ?024
Physical 'City,and Zip 21.REMARKS` 1 ,= Yr#
�c b� q(fi'Z 55g,coa 3
County Parcel Identification No.(PIN) err`{...
Sb.Latitude and Longitude in dcgrecsianinntes/seconds or decimal degrees:
(if well field,one!Wong is sufficient) 22.CertiSeation:
S'A°ZG 02r3'7/1 N o. " W fi2b72. _
Si of Well Con to
6.Is(are)the well(s): ermenent ur ❑Temporary By signing this foe;I hereby certi that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or 1SANCAC 02C.0200 Well Construction Standards and that e
7.Is this a repair to an existing well: ❑Yea or o copy of this record has been provided to the well owner
If this is a repair,fill ant known well construction bfonnation and eaplamn the nature of the
repair:older#21 marks section or of than bast of this fonts 23.Site diagram or edditionel well details:
&Number of wells constructed: / You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessity.
For naa/Hr/e byecticw or nor,-watersupply wells ONLY with the snare construction,you can
subndt one fare SUBMITTAL INSTUCTIONS
9.Total well depth below land surface S (fit.) 24a. For All Wells: Submit this forts within 30 days of completion of well
Fornmhiple wells dirt all depths 0.-cleereort(exanpk 00'and2®100') construction to the following:
10.Static water level below top of caring. ' . (It) Division of Water Quality,Information Processing Unit,
.(f water level is above caster$,use"+" 1617 Mail Service Cotter,Raleigh,NC 27699-1617
11.Borehole diameter: f (12 fan.) 24b.For Infection Webs: In addition to sending the form to the address in 24a
Rotaryabove, also submit a copy of this formwithin 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.eager,rotary,cable,direct push.etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Man Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test Blowing-Rig 24e.For Water Sunnly&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
Di,tintedion Chlorine Amount 50 OZ. completion of well construction to the county health department of the county
13b. where constructed.
Form OW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013 •