GW1--06338_Well Construction - GW1_20230927

WELL.CONSTRUCTION RECORD
For Internal Use ONLY:
' This form can be used for single or multiple wells
1.Well Coatttactor Information:
Bobb W. Potts 14.WATER-ZONES. I ,
Y . FROM. TO - r, DESCRD'IION
Well Contractor Name �p� I ! .. . , .
NCWC 2028-A ft tip:
. ft
NCWellContrsctorCc:tifiealionNweber •1S.OUTTERCASING(far madtlemedvidla)OR LINER Of )
PROM TO •• DIAMETER I THICKNESS MATERIAL , •
Ferguson's Well,and Pump, LLC D, q® tt 6 eAg.,.0 12/6r/25 PreSp,eZ /
Cc isp nyName • 16.INNER CASING ORTuB Nc( dosed low),'• .
} r� p PROM- TO- •. •.DIAMETER • TTIMMI SS' , MATERIAL .
2.We11.Constenetioa Permit#: • 17�ba O. C) DID 1 . . . . f. . . ft . . ',ID.
•
•:List all applicable well cCnstrnettori paints(i.e.County,giate,Varianca etc.)
3.:Well Use(check well nse)t 17.SCREEN.
Water Supply Wen: PROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL .
• l7AgricultUral DIVivai . fic .ft. ft . •in. ' ,
17Geothe:mal(Heating/Cooling&Poly) 'Cater Supply(single) ft ft • in.
' . Olndeesn;al/Cominercial DResidential Water Supply(shared IS.GROUT • " : ' • -
• . FROM • TO ' MATERIAL'. ''•m PL►eEMENTME1HOD&AMOUNT . •
. ohrigati . . . : . . 0 ft' 20• . ft Concrete • Gravity-Flow .
Now waitete r Supply Well: •
ft • ft 1
. OMonitoring : Ol ecovery .
. Injection Well: •fr. • ft
DAquifer Recharge. .: -DGrouadwaterRemediation. 19.SAND/GRAVEL PACK(if apple)
DA er S PROM: TO• : 'MATERIAL • •F.heLACF11t�ITMETROD.
. quif tatage,andRecevery; ❑SalinityBamer • f. ft:
'DAquifer Test ❑Stormwater Drainage .. •
OFxperitneatal Technology . DSubsideacc Control •
tt i r •
OGwtheaival Clusul • •20.DRILLING LOG.(attath additiimal shadsif'ry)
( 1 ) DTracor FROM. TO . DESOUPTION
•• OGeothermal(Heatmg/Cooling R ) _ DOther(explain under#2I Remadss) . 6• ft7 It., • . ity • . .
• .4.Date Wells)Completed: `i/ T/25 Weu MN . 70 .fc• . 5�S f t .. So Gi /�1 r/'®�4. • .
•
Sit.Well Location: gait.. i / V 4
qp YE,S. at •. ;. . O'x o/ e- .
(-1� triSCt I-(mersnr, . • . .• • ft. • ft .
' • FaeilityOwodrName Facfli #(if applicable) • ' ' ['� .-„'r rE -1
ft •
€. 6kak.-.�i +Jil.e.L)
• ':.tttic tY,Ln.Olsii. •r7a:ei) Oti-) AA 73.0 .ft:. ft• SEP -►. �/1
Physical Address,City,and Zip. • /^^ e :1.REMARKS " I•
, S C P 2 J 20 23
l t�M •
t0q 5 7��.Or 64 - lnt^ ..^;n11)rr.^=..N7ZT1 Uri:
County Parcel Identification No.(PIN) . [j;`a '-'i; •
"fib.Latitude and Longitude in degreealnunntesheconds Or:decimal degrees:
• . (ifwell'8eld,one IAA*is sufficient) . . 22 Certification..
3s©O Yi/rfo "i ri '' '.A!'.. .illt 3A6 " . . W. .
Si of • ed Well enactor Lia/aL
•
6.Is(are)the well(a):.QPerm�ansnt or OTemporary' .
13y sigrang Ali form 1 hereby cart*that the well(s)was(were)cautractcd in acunrdmra
with 15ANCAC 02C.0100 or 15ANCAC 02C.0200 Well COMOUetlarStandards and that a
7.Is this a repiirto am cnistngwell: - DYes- or -• ( • - copy ofthis record his beersprnvithdwihe well Ownar.
Ifthis is a rrtpair,fill oat larown well carsstruction b orination andezplabn*entente ofthe . • I'
• repair undo.#21renrarfo=don prim the back ofuisfom,. , 23 SIte diagram or additional well detl1s
J • : You may use the back of this page,to provide additional well site details or well
' 8.Number of welt.:constructed: • ( • construction details.;You may also attach additional pages if necessary.
• ' . Far:riadtiple hbeettaiarton-water sip*wells ONLY witht6eamneaauariidion,you ca i . • • . . I,
submit one for • SUBmrr ALINSTUCTIONS j
9.Total well depth below land surfacer • j•"• • (ft.) 249. For Ail"Wells: Submit this form Within 30 days of completion of well
For ntaldple wells list ail depth's tfaffere t(crumple- , 00'and2Q100') . • :construction tothe following: '
l
• 10.-Statie water level below top of casing. ' ,70. (ft.) Division of Water"Qnality,Inforntadon Processing Unit, •
If wader level is above casing.use"+" • 1617 Matz Service Cotter,Raleigh,NC 27699-1617
11.Borehole diameter. `` 4 cm.) . 24b.For eetian"WeIIa In addition to sending the form to the address in 24a
Rotary above,.also:submit'a•Copy"of this'form within 30 days of.completion of well
• 12.Wolf eoastiuction method: . construction to the following: j
• (i.e.auger,rotary;table,direct push,etc.)
. Division of Water•Qaality,Underground Injections Control Program, •
• FOR WATER SUPPLY WELLS ONLY: - 1636 Mail Service Cwiter,Raleigh,NC 27699-1636
• 13a:Yield(gym) . . .S •Method of tent:-plowing-Rig . . 24c.For Water Sunphi&•Inieelllon 7/ells: In addition to sending the fount to •
the,•address(es)above,also'submit one copy of this form within.30 days of •
- 13b.Disinfection type: Chlorine . 5 oZ, completion of well construction to the comity health department of the county
where constructed
•
Form OW--1 North CamlinaDoparomeatofEnvimnment and Natural Resonraes-Division of Water Quality Revised Jan.2013
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