WI0700323_Well Construction Record_20220429

03i05/2018 13:00 Kathy
(FAX)
P,002/003
WELL CONSTRUCTION RECORD
This torn can be used for single or multiple wells
1. Well Contractor Information:
BILL MAGETTE
Well Cumrador Name
2299
NC Well Connector Certification Number
MAGETTE WELL & PUMP COMPANY
Company Name
2, Well construction Permit x: W 10700323
Liu all applicable well penults (Le. Cartel { Slala, Varlarce, lnJeciloih Oct)
3. Well Use (check well use):
Water Supply Well:
°Agricultural
o Geothermal (leating/Cooling supply)
°lndustrial/Commerc ial
°Irrigation
❑ Municipal/Public
❑Residential Water Supply (single)
❑Residential Water Supply (shared)
Non -Water Supply Well:
°Monitoring ❑Recovery
Injection Well:
°Aquifer Recharge
°Aquifer Storage and Recovery
o Aquifer Test
°Experimental Technology
°Geothermal (Closed Loop)
OGroundwater Remediation
°Salinity Barrier
°Stormwater Drainage
o Subsidence Control
°Tracer
RtGeothemnal (Heating/Cooling Retum) °Other (explain under N21 Remarks)
4. Dale Wa1I(a) Completed: 10.15.15 Wcll IDN
5a, Well Location:
BERNIE DOUGHERTY
Facility/OwnerName Facility IDN (if applicable)
1409 POTOMOC DRIVE CHOCOWINITY NC 27817
Physical Address, City, and Zip
BEAUFORT
Por Internal Use ONLY;
IA. WAYtR ZONES
PROM
TO
DESCRIPTION
60 R.
160 tt
SAND & LIMESTONE
n.
ft.
15, OUTERCASIRO(for nrddtaaaed neellaYOILLINI€R(If an 1leible)
FROM TO DIAMETER THICl/Nt1R MATERIAL
R. C'EC. In.
Id. IRA(* CASIT.10 OOTOSING'feenther al-eloicd-loenl •
PROT,'
TO
DIAMETER 1 THICKNESS
MATERIAL
+2 ft.
140 D•
4 " I SCH 40
PVC
ft.
ft.
In.
17, SCRJEEN
FROM
To
numrtIR
SLAT SIZE
THICKNESS
MATERIAL
140 rt
160 fL
4
in.
.032
SCH 40
PVC
ff.
R.
In.
18. GR0UT
FROM
0
rt.
TO
120 D'
bry,TEIHAL
BENTONITE
tMPL\CEMEIhTMETI Ob A AMOQNT
TREMIE
R.
rt.
rt.
tt.
19,$ANIKRAV,ELpAC
tt. (Ic.Wblieibli)
FROM TO MATERIAL
120 °• 162 ft- SP 3
20. DRILL] 4G LOG (ahaeb additional 'Neehlf nectaaarp)
n.
FROM
TO
EMPLACEMENT hl ETIloO
TREMIE
DESCRIPTION Dolor, hardness, sell/rock Prue troth doe. ete.l
0
ft.
30 R•
30
n.
40 ft.
CLAY
SAND
40 fr
56 ft.
CLAY
56 R•
160 tt•
SAND AND LIMESTONE
B.
ft.
R.
ft.
ft.
ft,
21. RLMARRS
INJECTION CAPACITY 10 GPM PER FOOT OF RISE
County Parcel Identification No. (PIN)
SD. Latitude and Longitude In degrees/minutes/seconds or decimal degrees:
Orwell del& one Iat/long is sufficient)
35.492250 N—77.047165
6. Is (are) the well(.): OPermaacnt or °Temporary
W
7. Is this k repair to an cxisdng well: °Yes or DNo
1J'rhir u o repair, fill out known Nell eonafrrrclIar Iryformaoar and esplaln the halve of the
male under all remarks seelion or on the back of this form.
8- Number of wells constructed: 1
For NOV, I4/rcllen OP non-waft,.rupply welh ONLY with Me sane crrnslrucNar. you con
submit atm form.
9. Total well depth below land surface: 160 (ft)
For multiple wells list all depths ifdi fercni (example. 3 f 200' and 24100)
I O. Static water level below top of casing: 26
//Imrer le,'el la above easing, urn "4-
11. Borehole diameter: 8.75 (in.)
12, Well construction method: ROTARY
(1,e. huger, rotary. Cable, direct push, etc.)
(ft.)
FOR WATER SUPPLY WELLS ONLY:
I3a. Yield (gpm) Method of test
13b. Disinfectiontype; HTH Amount! 1.5 POUNDS
Form OW -I
22, Gar *lion:
Sign Care of Certified ell on
or
11.4.15
Date
By Mgnrng IN, farm, 1 Hereby cerl(ry that me ae11(4u'ar Overt) constructed in accordance
with ISA NCAC 02C .O100 er ISA NCAC O2C .0200'Well Cnn.wneeee &andante and rhar e
copy of this record has bem prevlded to the ,veil owner.
23. Site diagram or additional welt details:
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 necessary.
SUBMITTAL INSTUCTIONS
•
24a. For All Weal: Submit this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Information processing Unit,
1617 Mall Scrvlee Center, Raleigh, NC 27699.1617
24b. For Injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
construction to the following:
Division of Water Resources, Underground Injection Control Program,
1636 Mail Service Center, Raleigh, NC 27699-1636
24e. For Water Supply & I nlcllon Wells:
Also submit one copy of this fore within 30 days of completion of
well construction to the county health department of tha county where
constructed
North Carolina Department Of Environment and Natural Resources - Division of Water Reroumes Revised August 2013