GW1--06798_Well Construction - GW1_20241114

WEI:L CONSTRUCTION RECORD For Internal Use ONLY: • , "
This form can be used for single ar multiple wells
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• 1.Veil Contractor Information:
' • Bobby/W. Potts ' 14.WATERZONES_''.. . - . I I . • . .
7 'PROM •TO -' c' DESCRIPTION
Well Contractor Name ' ' • . . ft. 560 •R I
•
NCWC 2028-A ft ft
• NC WellContrectorCertificationNumber 15.OLTfERC SEN (formalfi rd'wd a)OR LINER(if sDpláble)
FROM . ' TO' •DIAMETER- ' THICKNESS 'MATERIAL
Ferguson's Welland Pump, LLC .
pa D 57 ft-(o( Zlt/9r/,ZS :. /�U��p
Comny.Name . '16.INNER CASING OR TUBING.(aeitheimal dosed-loop).;iv- • . .
. a FROM TO DIAMETER ' THICKNESS• MATERIAL
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2.Well Construction Permit#:• • . .��S� • ft ft. • iu•
'List all applicable well construction perinits(Le.Cowrty,Slate, . .Variance,etc.) ' •• ft tt , .irt
' 3.Well Use(check well nse)i '• •-17.SCREEN - ' . . . . . .
�'-'� Water Supply:Well: FROM. TO DIAMETER' SLOT SIZE 'THICKNESS MATERIAL .
❑Agricultural ' - ❑Monti blic ' • • f. . im , • .
•• OGeothermal(Heating/Cooling Supply) estC�f£ •dential Water Supply(single) ft _ . ft is
DlndustriaUCommercial. . . . • ❑Residential Water Supply( 18.GROUT .• . - . .
FROM TO . MATERIAL EMPLACEMENT MErROD&AMOUNT.
❑Irrigation • '
Non-water SupplyWell: 0• :: !` 20 Concrete Gravity.-Flow
•❑Monitoring •' • • my.❑Recov fc. ft •
• . Injection Well: ' • ft ft •
❑Aquifer Recharge OGroundwatcr Remediatibn ' ' 19.SAND/GRAVEL PACK Of au e) .
erStora e.andRecov FROM TO ' '• MATERIAL•} EMPLACEsmNTMETHOD•
❑A quit g cry ❑Salinity Barrier - • • . ft ,fti
•
❑Aquifer Test . •' . • ❑Stormwater Drainage, , . ft.
• ❑Experimental Technology ❑Subsidence Control . ' . . '' ' ' . " • ' 't:
20.DRILLING LOG.(attathadditinnal sheets ifneeessar) •- •
. . .' OGeutherinal(Closed Loup) . .: ' . . OTracer , . , • . . FROM TO -DESCMIPTION(color,hardness,soWroctt type,a[aln she,etc). . .
❑Geothermal(Heating/Cooling Return) DOther(explain under 421 Remarks). • / •
•�7 lr ��, rt 3S: .ft � �l�y
4.Date Well(a)Completed: / _.3�/2 7 •Well IDH . . S. .ft; �h .ft.. Ste!/( 5 /ram
( SO-ftV.5 7 `/
Sa.Well Location:.
7ft* S " 6C11a .
?It rInP( n'1Rtr�'•1Rnsi- OrQb t 4t. "- . . .
Facility/OamerName Facility.IDN(if applicable)•. '" •ft. ft ' . .,•>..4 . s�? '''..-','1:"
'l 1: • k -1 ux h if ilia lmnr-nlftci.'tl '- 69$?5 3 . • •• . ct: . ft ' , . .
' • Physical Address,City and Zip:. . •. •.. 21.REMARKS• . , • . • N O V 1 - .2-824
'\ "to tAiS _ Q 1'�7�+�Z,0 •�•].( 70 • i IG`.....,,... .'')_,-.,-,.•., - ,.,..-ts
County Parcel Identification No.(PIN) i; • • D: _-l r:
56.Latitude and Longitude in degrees/minutes/seconds or decimal degrees • I '
(ifwell field,one let/long is sufficient) 22.Certification•
" 0. " 1" / . i r ' " . " 1.) ' / - • '0/Ay_
. . •S f Cortriell Contractor.1 .
6.Is(are)the well(s (iedi'wei • •
•
): OPermanent or .❑Tctnporary . ' .
' 'By signing•this form,I;hereby certify that the well(s)was(were)constructed in accordance
' - with I SANCAC 02C.0100 or ISA NCAC 02C.0200 Well ConetructionStandards and thafa
'7.Is this a repair to an existing well:• DYes' or HNo ' . . - copy of this record has been providedto,the well owner. •
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. Ifthts is a repair,fill out brown well construction irfonnation andexplairr the nahue of the , ' • .
repair under#21 remarks section or on the back.of this fonn. . ' . 23.Site diagram or additional well details: •
'
'You may.use the back of this page:to provide additional well site details or well.: .
• 8.Number of wells constructed: I ' 'construction details.:You may also'attach additional pages if necessary. .
For multiple I,gectioa or non-water supply wells ONLY with the same construction,you cm • I '
submit onefonn• SUBMIITAL'INSTUCTIONS I '
. ' 9.Total well depth below land surface: e(Or ' (fk) 24a. For All Wells: Submit tbis.form within 30 days of completion of well
• : For multiple wells list all.depths differott(example,30200'mrd 44100) construction to the following: i. : . . ' . ••. . . .
10.Static water level below top of casing r-W • ' • . '' (ft) ' Division of Water'Quality,,Information Processing Unit, • .
If water level is above casing use"+" • . - 1617 Mal Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: `•` • ( (in.) 24b.For Inieetion Wells?: In addition to sending the form to the address in 24e
• •
'above,•also submit a copy of this•form within 30 days-of completion of well•• • •
Rotaryconstruction to the folloitin I ;
12.Well construction method: g:
• (i.e.auger'rotary,'cable,direct push,etc.)
Division of Water Quality,Underground lujectiott Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service C��enter,Raleigh,NC 27699-1636 • '
13a.Yield(gpm) ' .Method of test:.Blowing-Rig • 24c.For Water Srmply&Iaiectioa iWells: In addition to'sending the form to
. / the address(es),above, also submit one copy of this form within•30 days of .
13b Disinfection type: ChI •onne. �o®�, c I; / oz completion•of.well constriction to the county health department of the county"
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- . . where constructed. ; '•
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,'Form OW-1 • • North Carolina Department of Environment and Natural Resources-Division of Water{Quality . .. . .• . Revised Jan.2013 •• • •