GW1--06339_Well Construction - GW1_20230927

WELL CONSTRUCTION RECORD 1
For Internal Use ONLY:
. . This form can be used for single or multiple wells •
i •
' 1.Well'Contractor Infoniation: •
• . ' Bobb W. Potts • 14.WATER,SONES I
Y PROM TO• r DFSCR1P1ON •
Wan Co tarName ft / 7.5�. _ I •• . •.
: NCWC.2028-A _ n ? 7,0" • I 1 ' '
NC Well ContmetorCeitifcationNwnber IS.OiTfERCASING(for nmltremsed wells)OR LINER(if )
•
• FROM TO DIAMETER . TRIMNESS • MATERIAL
• Ferguson's Well and Pump, LLC C7 ft. . g0 6 1S 'hi' 1/�' S e I
Company Name • . 16.INNER CASING ORTUI ING(teMthermal ) . . '• ,
FROM TO . •DIAML+TER,. •TBICNESS MATERIAL ..
2.Well Construction Perinit#: r •bA.3 - 'bc1k1 a •fe • ft • • ; :in- . . .
list: all applcable well construcdon pandts fie County,State,'ariarue eta) •
. ..
. . ft. ft: • I,
.m.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: : FROM TO . • DIAMETER' •SLOT SEM TECteM.S4 MATERIAL • -
• . . IAgricultural DI hmJ •pal/Public ft •ft, ,
OGeothermal(Heating/Cooling.S�pply) . l3iesidential Water Supply(single) ftft hi _
ClndustrialCommetaial • OResidential Water Supply(shared) PR GROUT
FROM TO . •MATERIAL' • "•DAFLACEMENTMETROD&AMOUNf
Ohrigation • 0 ft- 20 ft 'Concrete'Concrete• Gravity-Flow .
Nen-Water Supply Wen:. • .
OMonitoring . ORecovery ft tt
Injection Well: • ft.. ft .
'• IAquiferRecharge OGmtmdwaterRemediation 19.SAND/GRAVEL PACE(If maul MOM • '
• DAquifer Storage and Recovery ❑Salinity Harrier FROM To. . MATERIAL 3 EtuIpLACEdffiVTMLRAOa.
. . R ft..
OAquifer Test DStomiwater Drainage R • R
OExperimental Technology OSubsidence Control - ' •i
.20.DRILLi4fGLOG.(attadtadditluaalshabsBatemaas)•.• : ..
OGeutheimal(Closed Luup) • OTracer • • FROM TO •. •DFS'Q ON(cola,badness,ao&Ucoctt tyre,cram sue,—,etc.) '
• OGeothennal(Heating/Cooling Return) OOther. (explain under#21 Remarks) . 0 ft.. : IL. '
Well(s)Completed: (S� 3 wealm# _9 _ fr. all ft • . 4,/4.r/`S 7 9f g .
4.Date We
�a.w . . 20 f 1/0 . ft . . i'A 54
Well Location: Yi1 q 7� 11
!t1 L�.C-• RS it • �'`P"Q'Wi 7e.
AJ c h IUt�• Ar ft: • ft.
Facility/Owncridame Facility lD#(if applioable) h ft: = .-F ° L,- j
3 ` �1I, F z.L_.t L..__y \! II •
—
a o /V C.t' y tar t( r i tiun cti. t5, I, ' . .ft ft:
Pttvsical Address,City,and Zip• IL REMARKS • . •• ' I, • S E P g 7. 2023 .
via;cory► h to a 5g (a a o-f3 '`a}t I
County• Parcel Identification No.(PIN) tll,v,ff"n.MC,J'
t
db.Latitude and Longittide in degreeshoinutes/aeconds or decimal degrees:
' . (if well field,one lat/loeg is sufcient) 22.Certification:
r
' 3s°30 3q/272.�'' N •.0°IS -94 75b r w gith 1Irr • [(1543—
/ signature of ed well Con
6.Is(are)the walks): L�Permaneat or OTemporary
By signing this fornR I hereby;MO drdt,the weA(s):was(were)catstructed dt aceoximuu
with 15ANCAC 02C.0100 or I5ANCAC 02C.0200 well:ConstnetonSimimdr and that a •
7..Is this a repair to an existing well• OYes .or HNo. . copy(}this tecord has been provided to the well owner.
rift's amp*fill oat known well consbucdon bfonnalion anderplain the nature of the
repair under#21 reassizsection or on the backofthisfomr. 23.Site diagram or additional well details:
/ You may use the back of this page to:provide additional well site details or well
tit Number of wells oonsttueted: . / '. . • construction details..You may also attach additional..pages if necessary.
For multiple!leach ornan-WateisupplywellsONLI!withthesane constitiction,you con
sub*ace farmo' SUBMITTALINSTUCTIONS j • '
2 I
3
9.Total well'depth below land surface: 0 go 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfalffemrit(esanrpba-.3@200'and 2Q100) construction to the following: .
• 10.Static water level below(top aicasmg: /0 (fit) Divisb t of Water Quality;Wormatioa Processing Unit,
(water1evel isabosie eosin,use"+" 1617 Mail Service Curter,Raleigh;NC 27699-1617
1L Borehole diameter. -` 4 (n.) 24b.For infection Webs: In addition to sending the form to the address in 24a '
Rota above, also submit a,copy of this form within 30 days of completion of well
• 12.Well construction method: ry-• construction to the following: . 1
(i.e.auger,rotary,-table,direct push,•etc.)
Division of water Quality,Lhtderground Injection:Control Program,
FOR WATER SUPPLY.WELLS ONLY: 1636 Mail Service C eater,Raleigh,NC 27699-1636
• : 13a.Yield(gpm) ' . 6) ' Method of teak Blowing-Rig 24c.For Water Sunnily&Inieetinn Wens: In addition to sending the form to
the.address(es):abova, also submit one copy of this form within 30 days of•
•
rub.Disinfection Chlorine Amount: _t OZ. completion of well construction to the county health department of the county
where constructed.
Form GW-1 North CaiolinaDepartrinent of Environment and Natural Resowoes-Division of WatoriQ lality Revised Jam 2013