GW1--06340_Well Construction - GW1_20230927

WELL CONSTRUCTION RECORD , '
%rioteraa1Use ONLY: '
-This form mole used for single or multiple wells •: . . :
1.Well Contractor'Inforntatiun: : . I _
Bobby/W. Potts. ,• 14.NEATER-ZON . I 1
PROM. .TO .� DFSQt1P12ON
' Well Contracarr Name-
• • • 'za:�. • L.'I '. . • . .'. •
NCWCO28-A n
•NCWellContraemrCertifiaationNumbar • ' . . '1S.00TERCASING(for tantlicaeedwdIs)ORL NER6f ) • '
. PROM' . TO- • DIAMETER I • TIC» • MATERIAL
Ferguson's Welland Pump; LLC ft a: j�;/2S' 'UcS /�ZI
Company Name• • • • • • • : ' . •• '• • 16.INNER CORM '• •
a' /� FROM. TO• :•DIAMErlR• • ' .THICKNiESS: MATERIAL -
• .'. '2.Well CoactraetiOU Permit#: • .aoea a" a.b.t q g. . . .ft - . . ft. • • . ' . ,in.., . . .. • - . . •
list aaapplicabk well eonstnectzon parents(Le Cowo:ty,State,Vana a eta)
tt ft in
. • •3.Well Use(sLeckwell use): 17.SCREEN. . i . : . . . -
water Supply Well: PROM: TO DIAME11rR BLOT s]ZE 'ImCRNFS9 MATERIAL
1:IA0a:i t:al• • . . • . ,• • - . • • D dick riblic .
QGeothatmal,(Heating%Cooling Supply) .,r3 dential Water Supply•(ogle) ' .1' . . ft • m -
Olndustrial/Commercial. . OResidential Water Supply(shared) 1&GROUT • ' • ' . •:i . . ' : . :- • • '
FROM. • . •TO ' . • : •" MATERIAL " PMPLACE ENTMEiH)D 3 AMOUNT
Olrripatian • . .
Non water Supply Weil: 0 ft '20 . Concrete Gravity-Flow , • . • .
OMonitoring ORecovtay ft. ft _ . • . •
Injection well: fa ft
OAquifer Recharge. • • . ❑Groundwater Rernediation • • 19.SAND/GRAVEL PACK{if ID di e)
q er . 'gc very' .DSalmrty Barrier :
FROM• TO MATERIAI.•s METHOD.
OA Stoic �andRuxe .R' .• � '. '
. •OAquif.er Test. . . . OStomtwater Drainage, . "''
•1:expetimental Technology. . : DSubsidence Control - • . . . '
• • 20.DRU1 (GLOG addiulisoosisheslsif
: •OGeuthe al(Closed Loop) : ' DTmcer : ' : FROM•• TO • •DESORP ION(,eabnew,sdurock4ae,gramsire,etc) ' '
. DGeothermal(Heating/Coaling Return) ,• DOther(explain under#21 Remadts). . .: 0.ft .•0. •It ' .(/G.y ' . .
•
• • / . S dit'. r/ 0 .ft. . j .5��O1S1T9 .
• .4.Date Well(s)Completed: . t V' Well YD# fG. (I' .7. ft • • :, ,
sa.weII Lm:ation. • • • • • �• ft •
. Facility/Owneillame . • FacilitylDit(if applicable) • • • '
ft ft .r..77....(7,tl_:_C 11 �F7,
: 'ts-t' CIA- • Street (aShe�.auck. .'a 886(0 . • .ft.: ;ft . ,'• :�, U .b:,� ..*•� L.'.r •�, A.....1„..,
Physical Address;C and Zip' '
• r . . . 01(�g6 I LI �I Zt.REMARKS �E r �O23
.County Parcel IdeetifcationNo,(PIN) . n..c.ir .,;I { -,".:'.9 Uri .
5b.Latitude and Longitude in degreealminntes/seconds or decimal degrees: :• '{ `•a 1"
(if wall field one let/long is sufficient) : ' . 22•Certidfcad : • • •
•
/ . :Signature O Well trac rue
•: 6.Is(ors)thevial(s):. •"2.1aaneat. ur. C1--theporary. .• . . : . ' • '
• • B1'slg»ing tfds far/b I hereby�•J'�Sr�lhe weD(s)was(weref caesfrircted bi acaa{dmra'
• '- . wlth'JSANCAC 02C.0100 or ISANCAC 02C.0200 Well.Constr�4'onStandards towI that a
' • • 7.Is this a repair to an'existing•viell: ' OYea .or '0No • : • ' • , 'copy gfthis secondheis been pmvi&d to die well owner. . '
. 'tjlhis Is a repaoir,Jill out blown well construction bf rinallon and exple*,the watery of the . - '' . '' '. . • • • . • • . . ' . ' • - •
repair under#21 rosaries Ilan or on the back.ofthtsfoim . • 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 wets constructed: ' ' '• '/' • ' •construction details.:You'may also attach additional pages if necessary.
• For riarldpkbfectiatorton-Water Supply wells 01VLYwwth the stone co!tstroction,you curl•• .
sullntt One farm• ' .• ' • • • . • • . • • • - • ' • - 'SUBR�II1TALINSTUCTlONS • I,•
9:Totalwell depth below%land surfaces g ' (ft,) ,24a. For All Vella: Submit'this,form within 30 days of completion of well .
.• .-Fornwuilpk welts listalgepthiledgrerivet(ermnple-3@200'and 2@1(10) . • . . . . :constructionto the foIlowing: G ' '
: •'• 10.Static water level below top of casmgi. •• . •. .2 •0 • . r (tL) Division of Water Quality;Information Processing Unit,
' "• ,roarer level isaboree ecstasy use"+" - - 1617 Mail Service Curter,Raleigh,NC 27699-1617 •
• • 11.Borehole'diameter, (m.) 24b.Fair Tnieetion Welid In addition to sending the form to the address in 24a
this!foim
' - above, also submit:copy,of. within.30 days of completion of well.
1 .Well:construction methods Rory : constmction to the following -
(L.:a+ger,rotary,:cable,direct push.etc.). . . . -
• .
. Division of water.QuaHty,Un�del uad Injection Control Pengtarit,
.- FOR WATER SUPPLY WELLS ONLY: •• ' • ' . 1636 Matt Service Center,Raleigh,NC 276994636 • • .
• . ' r3a.Yids:(gpin : /ff• �/•ry9 • o Blowin Ri 24c.For Water Susnuly&Iniecti .Wr1L: In addition to sending the form.to
i,v ' Method of test:' 9 g
. . •• •• .• • the..address(es) above, also submit one copy of this,form within 30 days of
• 136.Dis.•• ' ••.a ty •pe:'Chionne, A�nae- • S0- • oz-• •• completion of well construction"to the county health department of the county.
. .where constructed.
Form C-W--II : , , . • North Carolina Depertorent ofEnviminneat aodNatrual Resources-Division of Water Quality . 'Revised Jan.2013. •