GW1--06325_Well Construction - GW1_20230927

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WELL CONSTRUCTION RECORD• . •
. . , For Internal Um ONLY:
• .: This form Ma be used for Single or nitdtiple wells • . ' ' .. . I •. ' • ' "
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' .. • .1.Well Contructer Informatien: ' . .
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• BobbyVV. Potts. . • ia.ivATER-ifoirs, .• . . r I
- FROM ' TO • . f •DFSCRUTION • • . ' .
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. . Well Commitor Nein;• • • • • • . • . ; :: •ft' 2/0 :a. . 1 I . .- . • .- : • . • ., ,
NCWC 2028-A -.• . . . •
•ft• : . ..• fe. :- • .1 :. -:. ....' • .. : • : -
. . • 15.OUTER CASING(for nmItkaisalmeRs)OR LINER Of ) . . .
' • . NC Well Contractor Certification Number ' ' •
' FROM TO. . DIAMETER i . TERCEPIESS .MATERIAL •• .
Ferguson's Well,and Pump, LLC - . . . . .- (9.f' . tft. ‘‘.A:S..,h4 7/4:41. i.5 Oc$,P2i
.- ..-• 16.INNER CASING ORTM1ING(geothermal d •loaD)
• FROM. TO ' •DIAMEl'ER' VIICKNESS MATERIAL ••
• 2.Well'Construction Permit St - . 202..3.--0()(44, . - . ft. • •• . ft •l' in. ' ' ' ' . •
List al I applicable well ceoss•Intetionprtits(te.County,Stgle,Variane4 eta) • . .• . •. . ' . .
. '3.Well Ike(check well use): • • ' • : • 17
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. . . Water Supply Well: • ' - '• •. • .. • • FROM TO • DIAMETER: SLOT SIZE 771ICENESS MATERIAL . .
' • . t. -• ft. -• • in. , ' .• , .
°Agricultural: ,- : '. . .• .0Municipal/Public •' , •
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• ,, • OGeothetnial(Heating/ceding SuPply) Clieridential Water Supply(single) • . .ft' . . .ft. in
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• ClInclustrialicial : ' ci404ential Water Supply(shared) la id°. .TO. •. . . •MATERIAL.. EMPLACEMENT-METHO D&AMOUNT
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0. •fc• 20 . . ft. Concrete. Gravity-Flow . '. • .
• Non-Water SOpplyWeli:. • .• .., - ,. .- . . • . . . . ' .. • .
'ElMonitoring ••. ORecovery . ft ft
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. . Injection Well: - ' • ft. ft
' •-'°Aquifer Recharge - '• . . ClenctindwaterReMediatiOn-' - 19.SAND/GRAVEL PACK Of anullailble 1 - ', . . " • -• . - '•
FROM. TO • MATERIAL. - EMPLACEMENT METFIOD "•
. OAquifer Stcauge and Receiteri OSalinityl3arrier.: ' . • , • ' • . , i. 3 ., .
•°Aquifer Test • OStommater Draina. ge , - . '
• .0Experimenial Technology • . - DSubsidence Control , ,
.. 20.DRILLING LOG.(attarhaddithiniI ebeettifneazsasy)' . • • . - : . .. . -
. . . CIGeothermal(CluScd Loop) . - • Cirracer . . : • • ' PROM• TO DEStEIPTION(color,berthas.solltrock Me.stain die,de) . . . ..
. ' °Geothermal(Heating/Cooling keturn). . 00ther(explain under 021 ReriSadM) . ..:0 .r.e. (/0 .'M. . ' . . eltdy. - ' . • • • - ' . .
. . • •VO r•t‘ ,S:5. •" sooe,s Yeetic . . . .
4.Date Well(s)Coinpleteshefify2f23 Well ID# •
ft.: ...1 it. . . ..P'e /0C
1•SR.:Weil Location: _. ' . . . • ' ; •,' .
‘,,,k- ft. , 2V_6 ' . ' 6-tauj/*l et ., '
• 7-PiArt e2,-/ (i_• &.)n.). I I.r,..,• 1 ' - • .• • . • • • •ft. ' • • ft. 1
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Facility/Owncrblame - . - •-. . Facility ID#(if applicable) : ft. . ft r ' P L"7:•rt FL;1) !PTY.
izruij- :Et)la: I. .L ei r egt_r7" ••••17(-1 8 " - - fe. • . • 'ft- 'I.. - = '''"'-'71-. 7'•- ":"-'7. • :• " .
. : Pivair.al Address,.City,and Zip: ''.-- :•• : -: - - •-. • •. " ' - : : • :
21'REMARKS . ' ' • • SEP 21 411'i' . .- - . .
. " s.tie..C. 1:_..hitiL L?. . voigiolgi ) . - • ,• . • : - . . .. . _,. .. , ..,
. .- Candy ' ' , ' • , Parcel Identification No.(PIN) • t. trtfoi-Act.4;:f....11 eft.-.-e.;;,-...v-ik..-:-,;.;...%,,, . •.
. Di:sir:MIN:1 . . • - : : •
Sb.Latitude and Longitude in digrees/nriM.ites/seconds or decint2%1 degrees: • ..
:2A.,Certification:. . • ' •
"•. (if well field,one lariong is sufficient) , • ' . : • . • • •
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35°.3 6. //c,3A ry . N 4.A o Vs zVogr/
si. .. . ed . COn tdi •- . ' '. • ,.Date , . 1•
• 6.Is(are)the wal(s):.131aannit 'or• OTemporary - •• • • •Siaigning this fortni!week;certikihri;tlie well(s)lea .(were).eieistructeel ft:del:Oda:nee
.• •: with 1.5ANCAC 02C.0100 or 15A Malt'02C.0200 WdlConetruetion tandarels and that a
• 7.Is this'a repair to sa er6ting Well:.: 0Yes. or Zile' ,• " '. - • . co it y of this secoidhas Beerspioviehd tothe wel I oWner. ••
. tf Mists are-017,P ce4 Iota=well eottshuetionittfotinatien and explain the nature ofthe ' ,, • •
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• repair tinder#21 reetaski stabil er ,On the brick of this fonts • . - •. 23.Site diagrain or sidditiOnsd well details: ' . • . • •
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• You may use the back of this page'to provide additional well site details or well.
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S.Number of wells anstineted: • . ../ ... . - • '' 'Construction ditaili You May also'attach additional pages if necessary. '• ., •
•. For rineldple injecticetornon-wahr euppOvells ONLY with the sante etinteritetion,*et eine ". '• • . ' •' . ' . ' • . . . ... • • •
SITBEffITAL INSTUCTIONS ,
. • . 9.Total weli depth below laud surface: 5 q'•• . . (ft.) 24a. For.All Wells: Submit this form within 30 days of completion of well •-
. :iFortnultiple well s list,a1 I ektpdteedtehnitzt(example7;3.@200'anel2@l00) . . construction to the follow*g: . ,. • . •
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10.Static water level below top of casiigi • • ' 4(0 . •*., (ft) Division of Water ctualitY,Infoimation Processing Unit, .. .'
.1(Watei level Ls above easing,rice"+" . • • , - 1617 Mail Service Cesiter,Raleigh,NC 27699-1617 • • •" . •
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11'.Borehole diameter .- . 41.2 .(in.)V'I.- ' • 24i.Per 1Intibtrion Wells: In additiOn to sending the for to the address in 24a • * .
above, alio sutroit a copy,of,thik,form%,vitbM 30 Clays.'o,f.completion.Of well • , :
IL Wei construction 1111itiod RotarY . : . : • construction ti.3the folloning: i•
' . (i.e.auger,rotary,cable;direct push,etc.) . :
• - Division of Water Quality,Underglimul Injection Control Pmgram, . • -
' FOR WATER SUPPLY WELLS ONLY: - • ' • 1636 Mail Service Center,Raleigh,NC 27699-1636
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• , ..,. BIOIAilligoRig 24C.Far Water thunnir&Iniectiart Wells: 1naddition tO sending the fomi to - . .
' 13a.Yield- •(gpm) ". •''1 n . " . .Method of test:"
'the address(es)above, also,submit one copy of this form within.30-days of:- "
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.. .: . •Chlorine : ...: Am'lin. • t. ' . 64. . .o.i. . mp
co. letion. . of*ell construction•to the county.health.department•of the county
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- 136.Disinfection tYpe: • •
.where constructed.
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i Form OW-1: - ' . - 'North:Carolina Minato nt of Environment and Natural Resources-Divisien of Water Quality ' Revised Jan.2013 •
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