GW1--06463_Well Construction - GW1_20231002

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' • : WELL CONSTRUCTION RECORD - - .
For Internal Use ONLY: . .
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• : This form ash be used for single or multiple wells
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• • 1.Well Contractor htformation: - • • .
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• -Larry W. Ferguson . .A
son 1 WTER ZONES' -I .
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PROM TO DESCRIPIION •
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- 'Well Contmctor Nam - ft ( 0 ft I I • - ' •
. . NCWC 2029-A •. ft. ft• I I . . • -.1 . . • . , . ..: .•• . : ' .
- . NC Well Contractor Certification Nunrber IS.OUTER CASING ffernadtkised walls)OR LIN1016f ainfteable)
PROM TO ' DIAMETER - THICKNESS MATERIAL • .
• . • : fergueon'a Well and Pump, LLC ...?, •ft• 2 1• f`. .(0.,05-: i 11- 05.4)rosbp.,14:. .
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: . : Coinpany Name .. • 16.INNER CASING OR TURING(exothermal dined-loop) - . - •
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. „. ., FROM •TO .- DIAMETER ' • THICENFSS MATERIAL
' . 2.Well ConstructiOn Permit ti: . it(0 40 ' . • ft - ft: •
. • List all applicabk Well congruence:pent:ft(La County,State,Variance,ita) .
• ft. ft. • in. . • •
, -3.Well Use(check well use): . i . . 17.SCREEN • • -.-- • - . • : •. .-
• Water Supply Well: • .FROM TO .• .DIAMETER SLOT SIZE THICICNESS MATERIAL '
in. 1 •
0Agricitiftiral . QMtmicipal/PUblic - D. ft •
- 1:3Geothermal Heating/Cooling Supply) °Residential Water Supply(ciogle) • -- ft - ft i V .
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• 0Inclustrial/Consnettial • ORekidentialVater Su.pply(shared) -Loa GROUT -TO : ..
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MATERIAL , Eatrumnaterwirrate a amourrr
• • ClInirration : . . .
Non-Water Supply Well: . , . 0. ft '20 • ft.:' Concrete GrivitY-Flow' „ . .
ft - ft :•;
• 0Monitoring . • ' . OReetniery .
Injection Well: - fr. . ft - 1: • : • . . . .,
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. . °Aquifer Recharge • 13Groundiviter Remedied= - . . .
19.SAND/GRAVEL PACK Of smolimble) • •
FROM TO - .• MATERIAL "• EMPLACEMENT METHOD
CLAquifer Storage and Recovery 0 Salinity Barrier . 0 ft. Or' ft - ..
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°Aquifer Test 0 StormWater Drainage.
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I:Experimental Technology °Subsidence Control . .
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Goo :2A.DR1LUNGLOGfattadt eagle:al sbecesifnecestarel -- - : - - • .
- - ' 13thermat(Closed.Loop) CI - . -
Tracer FROM TO_ • ,DESORPTION War,hardnaso,soWrock type,grain due,etc)
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CIGeotheimal(Heating/Cooling Return). °Other(explain under#21-Remarks) A/ ft-‘2,,, .0•f4 f. 7W.....e-hiOd/04.1
• ft ' • It . • •
• it.Date Well(s)Completed: Ar°O.V23Well Mg .
• . ft • l't" •lIPil, 0 , /1-litezrk. • - • •
- Sa.Well Location: • .
Facility/Owner Name . A' Facility ID#(if applieable) IL Ni
dolitoiti..;., heare. indisitaLi. A t 0.75 3 •
ft. .. . ft. . ,
Pay Addreas:city,and Zip . . '• • — ' • • OCT 0 2 ?023
. .... 21.REMARKS. i• .
ffladzAs-k) . . . .f794 lac;tc,,ath...71 .rN.7*.q447,3 Ur( •
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County . Parcel IdentificationNo.(PIN)
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. . 5b.Latitude and Longitude in degreeshninutes/seconds or decimal degrees: 2•2 cab ij -
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(ifwell,field,one Wong is SuiEdent) • . , ,
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• 35 76#7 i .2.7" N 13 i.• .0 a Cil" .5.9.401 w e'4 . • . . . - l' : 641.' vfre . :
• Signature of ed Well Connecter . . .Date
• 6.Is(are)the well(s): Sierroanent or °Tem . s
porary 1_ •
By igning this fem. •1 hereby cent&that the well(s)was(were)constructed in egoista:Ice
with 1SA NCAC 02C.0100 or 15A NCAC.02C:0200 Well Construction Standards.and that o
' 7.Is this*repair to an existing well: ClYes' or No copy cithis recordhas bectiprOvidetl to'dw Well owner.
OAS is a repah;fill ma knownieeg*instruction bformation tad explafri the nature of the 1,
repairsoder#21 revues section or on the back of Misfonn. , • 23.Site diagram or additional Well details:,
You may use the back of this page to provide additional well site details or well •
• S.NuMber of wella constructed: •- / • . V construction details. You may also attach additional pages if necessary.
For nalltipk,h(pcnonornon-water sitoply well aOlVLYwith Mesons;construcann,you cm •
- submit ase lona SUBMITTAL IRSTUel'IONS'
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9.Totalwell depth below land saris= • t4 6 at) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths trdifferent(aton*-3@)200'and 2(§10(0) constructionto the following:
- •10.Static water level below top of casing: /6 40 ''' (ft.) Division of Water titMlity,Information Protesting Unit,
• rwata lesiel is above casing use '+" 1617 Moll Service Center,Italeigh,NC 27699-1617
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• 11.Borehole diameter: LIZ Om) 24h For Injection Welts: In addition to sending the form to the address in 24a
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above,also'submit a copy of thiS form within 30 days of completion of well
12.Well construction method: R°;arY construction to the following:
(Le auger rotary.cable,direct push,etc.) • .
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Division of WateiQuality,Undergietmd Injection Control Program, ,
FOR WATER SUPPLY WELLS ONLY: . • 1636 Mall Service Center,Raleigh,NC 27699-1636
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24c.For Water Suisolv&Injection WEIL: In addition to.sencling the form to •
13a.Y.idd(gpm)- •7. Blowing-Rig
Method of test . the address(es) above, also submit one•Copy of this form within 30.days of
• h- • C lorine • .• . completirm,of Well construction tO•the county health.department of.the county.
•. 13b,Disinfection type: Amount: .a • Oz.
• • where constructed.
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Form GW-1 North•Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013
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