GW1--06386_Well Construction - GW1_20231002

. -WELL CONSTRUCTION RECORD : Forlateraa Use ONLY : • •. '
Tliiis font canbe used(c rsicgle or multiplewalls
1.Weil Centimeter Informadon: : • . : : ' .
Bobb W. Potts: 14.WATERZONEas .t , .. .:
Y FROM. TONES. r. DEst3�11ON
' .: Well Coageetor Name . : • • • ' . ' ft 0. • • .
: . . NCWC 2028:A ::: •. , t •
.:NC Well ContmictorCeitifieationNumber ' • . •1S.OUTERCASING(for mulfi+asrfirdla)ORIJNER(ife cable) '.
FROM . TO . .DIAMETER. • THICKNESS . MATERIAL'
- : . ' Ferguson's Welland Pump;'LLC - . : f 5>k. - :6,..n :a fj.8.._. ,} :1 .r l
CompanyNeme /V� Z 3 2 16.ININERCASIIVGORTOBQIG(�14o1lnnnaldmeddacp) '
wa p��t eaPr 1 ppinTls o ray�c 5 .-- -, -0 1 etc,) .6 4 '.. FROM.R . . . R :Di. . . .., _• .ffiCIalE.. . MitT.. .
:3.Well Use(cheek well use): • : - • .
R ft.
. Water Supply Wells : . • . . FROM.• TO' DIAMETER SLOT maTom"— MATERIAL .
❑Agriculhiral ❑ capal/Aiblic it- it . im .
❑GeOthamal.(He;atingiCooling.Supply) ,. Ceslddeatial Water sin in. • K• ' ft h " - •. .
�PP1Y( S ) •
DIudustrial/Gommercial. . . l7Rexidemtial Water Supply(shared) is GROUT To • . : • MATF1tTAL. ' :EMPLACEMEc-
. METHOD..AMOUNT
❑Iai�tion acre"
Non-Water Suppli'.Well:. ..' . ' . . . �': •IL, 20 ft Con Gravity-Flow
❑Monitoring . . ' . ' " . ❑Recovery • . ft . . . . . .
' . • Injection Well: • . ' . ft fft
°Aquifer Recharge••. .. ❑Groundwater Remediatioii' 19.SAND/GRAVEL PACIi of awe) • ' :
quifer Storage and Recovery .-OSalinity Barrier . ' :a
' • ' ..
❑A FROM TO MA METHOD
❑Aquifer Test • . ' , , ❑Stomzwater Drainage, .
.❑Experimental Technology ❑Subsidence control , .i. �,. •
: •20.DRIr(G LOG.(attadt ad+ll6a at abeeis if l .
.• 'batanheninal(G1uSpl i oop) . . ❑Traces' . - ' . . ' FROM•. TO • •DERCISPTION(mlar,hardness.gamedt 47ea Brain die.err) .
• ., I Geothermal(Heating/Cooling Return) .DOthes(explain.under#21 Reatazksj ft ft .- • ..' • • • •• '
• , .4.Date Well(sj Completed: 5��;�:Well ID# • 1`
Sa.W Location:.
• . • V.5 R f4'.� it. • 1, -.rail 0 Y-04.c. :
rej,9i . .Dfcy'�!c!�'4L.5 • .'. . .. .. . . V.
. s 7 ft. / / . .
Facility/Ownerilame-` :FactlitylD#(ifapplicablej ' •. • r jf S ���1 ' C�il/'(�.�/
-'1{.�. 'Penrys [ii14y- : •4endizrSorl�itL. .a.s'7Sea • . tr.. • ft: �• • .• '
C. aaa Zs 2t.REMA :
PttvsicalAddFcm;city. p "`? - �4 r l\•. N.... •
. (curler SD v� q 1e 9-n Li A'5 044 • . b .,‘.,.!ii....,.t to x.A,e,r.,' .
County Parcel Id, Paea S:lin s:No,(PIN) . :OCT:0 '2 2023 .
Sb.Latitude and Longitude in degreesi.minntes/seconds or decimal degrees: •22.CertiScatioa: _ Lrs
(if wall field,one lanloag is sufficient) -e ,, 3
:35 jal 3.S 'S y N. $OLa-4A ' �/r.'3) r.�'''. w . ' y:/, / • •'` ss 0 .3
�" Si ' ed well Contractdr. ; " . "I)a .
6.Is(are):the well(s):,giPet ianeut or .❑Temporary I,` . .
• BY�8�8 '�.form�l hetieby eer2�y thaJ:the weA(s)was.(were)corserscted if.'accordance
with ISANCAC 02C.0100 or 15ANCAC 02C.0200 Well CaiutrucdocStarrdar.*and that a
7.I,this a repair to an exlsting.well:•' filtra ; or ' ❑No • • copy of this reconlhas been provided to the well owner.-.- . • .. .
411rIs is a rrpak ill 1Old biOwn well consiruction*don and erplabt the wale. of the . • 1; .
repair under#21 remaikssection or o»the bade gf this foam. 23.Site diagram of additionaiwell details: • -
I
. .You may Use the back of this page,to.provide additional well_site details or well.--• .
. S.Number of wells constricted: ' , '• '" construction details.•You may also attach additional pages if necessary.
FornwidpleWeak*:ornan-wared.*ply wells ONLY with ducat=coristrection,you eat' :'. l; -
submit a>rafoeus' • SUBMITTAL'INSTUCTIONS -
9.Total well depth belotrlandsutface: ' S®:S (ft.) 24a. For All•Wells: Submit this`,farm,within 30 days of completion'of well
. • Formrrhiple welling!all depths tfc�'eiazt(esmnple-,3(a�200'ard2@100') . construction to the following: . 1, . .s . : •
10.,Static water level below top of egg. • j a f (ft) Division of Water Quality,Information Processing Unit, .
Ifwarer level ls above easbrg;ire"+"' ' -' " 1617 Mail Service Center,Raleigh;NC 27699.1617
11.Borehole diameter. ` 4- (m,) 24b Foie Ini.xtian Welir In addition to shading the form to the addres•
s in 24a ' •
'above,.also submit a copy of.this foam within 30 days•of.completion.of well
: . 12..Well construction.methode _Rota1• • c natructun to the following .
. (i.e., rotary:cable,diree:push,eta) j.
. . . ' . . . ' ' . . . Division of Water giality;Undergromtd Injectie t Control Program,
- FOR WATER SUPPLY WELLS ONLY:• ' •• • 1636 Mail Service Center,Raleigh,NC 27699-1636. • ' .
•
• 13a.Yield(gpui) • . Blowing-Rig • '24c.For Water Suety&-hdectl Wells: Ia addition• to sending the form to • .
S. Meheelt of test ' 9
. . - the address(es)-above, also submit sine copy of this form within.30 days of
. jib.. Disinfeeticn 'Chlorine.' . :..Amount: • • . j;, ) • oz. completion of:well conshuctioa to the county health de9parmient of the county
( where constructed. �� .
FormC11V-1 . • ' North'Carolina Department ofEi,vimnment mid Natural Resources—DivisionofWater*v....ty , . , . . RevisedJaa.2013 •
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