GW1--06473_Well Construction - GW1_20231002

" TV Jall.J.EJ 4....V.111.71.1%.11:J11.•J.XVII-AMT.-AL/LW • For Intenial Use ONLY: 1 •
. This form can be used for single or multiple wells
. .. . . • . . . .• . . 1.Well Contractor information: . . • • • . . . . •
• • •
. Bobby W. Potts. .. ' ' - • - . ' . 14.WATERZONES.,• • • • . -1 : ' • • • . .
. FROM . TO .- ,• DESCRIPTION ,
'• Well Contractor Name • ' - ft.
• efOO ft• - •
- NCWC.2028,-A . • ' -.
• •. . It. pia:ft- - 1 1. _ . • • .
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• ' • NC Well Contractor Certification NUMber : . '. • , • 15.OUTERCASPIG(for multicasedittlis)OR LINER(if separable)
. . PROM• TO • DIAMETER •THICKNESS MATERIAL
• Ferguson's Well and Pump,-LLC • . . - . . . • (9• fi; CASING ft-Zr 2:SI in..216/1AS Oc5p42/ • ,
Company Name . • ' • .• 16.INNEROR TURING.Oserabermsd dosed-1000 ' • ' • -
i.,' ..„,. .,,. „ ' ' 'PROM . TO DIAMETER THICKNESS • MATERIAL
2.Well ConsttnctiOn Permit#; . U b 5 --2023.-y/305. . ft. ' • ft • ' ' in.
List all applicable well construction pennits(Le.Comity,Stale,Variance etc.).- • ' • " -, •
ft. ft I. ' in.
• .
3.Well Use(check well use): ' 17.SCREEN I - •
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Water Supply Well: .„. . •
. _ • PROM TO . .DIAMETER •SLOT WE - THICKNESS MATERIAL •
•
. . • ft . ft . :
.
0Agrienitural . . • •.
OGeothermal(Heating/0:1°1in Supply) . ft 41- - . •esidential Water Supply(single)
Clindustrial/CcmmerCial' . CIResidential Water Supply(shared) IS.GR°131. • . ' ' . -
. . FROM . . TO . MATERIAL EMPLAcENIENTMEITioD&AMOUNT
- ClInigation• - •. . •' . . . - .
0 supply Well:, • , - '•, ft. .20 IL Concrete. Gravity-Flow . . . . ..
• • . . Non-Water • - • • . : . - .. - • • •' •'
' .-
°Monitoring' . . 'OReCovery . ft.
Injection Well: .. • .ft.' ft
• ft. • 1 .
: °Aquifer Recharge . ' . Ogromidwater Reim:dation . 19.SANO/GiAVEL PACK&Isnelitable) •
PROM - . TO MATERIAL , EMPLACPMPNT METHOD
°Aquifer Storage and Recovery °Salinity Barrier - ' •'ft • ft: , ..
ciAquifer Test - - • • • OStormwater Drainage • • ' . 1' ' •
ft.• ft ,' .
.. .
• °Experimental Technology •-' OSitbsidence Control .: ' ' t •-
.' . •2&DRILLING LOG.(sittachiddi&tiral sheets ifneagsary)
• °Geothermal(Closed Loop) . . C1Trater - . -PROM • TO •DESCRIPTION(calor,hardness,soturoeu type.awn site,elx.) • •
• , °Geothermal(Heatingkooling Return) °Other(explain under 021 Rainarksj '0•'ft• g_d 'ft (:C/it y ,: . . .:. . .• •
4.Date Well(s)Completed 7a ,2 3 WellIDN ' • -
/
' . . . . • ' . 3 5 'ft.. e/f' ft. ' .1;14,- fac1C. . . . •
. • . . . • : ' . . • • •
. W 'ft.• ..605 ft. . .
. ()-Ttic i-c. Ity 4.• toa-14-)Ntl•pinee.e. . ... ft.. . ft . .
. ..
.. . „ . '
. •Facility/OwnerName !'," 'Ts' . Facihty Mit(if applicable) '
. • ft.- ft c,--;;; ..; .."t.:r:f,I
- tooa . ..es•Ver Cy...celc. 0,3 Re ry-Liircr). miff le- (2(37 ti.P. , .ft.. • .rt., I,
CIi) '2 1073 • ' - •. ..-pkisicailiddres.,CitYilindZiP . ' • - • • . '' ' ' • , • ' =REMARKS. • .• . . - .' . .' ' 0- - • • -' •
- r rl.k erSeorN •
. O ." ' " • - . 149ga7 7 344111. . • • • - h „ ,i1,...-,Prz-4:51.5q4r:g 01-1S
..
litil-A"-"'. = q91-••:2 County • •, . ' • . . , , • Parcel identidcadon No.' .
(PIN) - • . • !: • - - DM;Cti--,‘-`N• .
1 .
•Sb.Latitude and Longitude in degreesimin' utes/seconds or decimal degrees: ' .21
. . . , ' 1 Certification'
at,i7,on,: ww.ei o
_-
• (if well field7 one latilong is sufficient) • . • . • ,
35964 ) '34k23 w Si , ci -
.....,..- • .
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:6.Is(are).the well(s):: Oirmanent or pTemporary , . • -By signing this form,I hereby'certi),*Ft the wea(srwas(were).Con.structed in accordance, •
•.
• with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a •
7.la .. .
this a repair to an existing well: 1:3Yes or • .• o copy of tlds record hat been proVickd to the well owner. .. .451
• MIAs is arepak fill out known well constructioribformation cord=pleb:thenature of the • • ' • • • ' . 1: - •
• • •
•
• repair under#2I remarks section or on the back elk:Vann . ' . . •23.Site diagram or additional well•details: . . '
You may use the back of this page lie provide additional well site details or well
:S.Number of wells Constructed: . . • /.• . .'• . . . . . ' . '. . • construction details.-You may also attach additional pages.if necessary.
For nethiple bgecdon or non-water supply wells ONLY w i th the Aware constradion,you con • ' • •
• submit one forrn-.- • • ' SUBMITTAL INST.UCTIONS 1. •
• a
9.Total well depth below land surface: • fr '- . (ft), '24a. For All Wells: Submit this If=within 30 days.of completion of well
For muldpk wells list all depthsV(referent(exampk- @MO!and 2@,101).) • construction to the following: I. .
• . . . .
10.Static water level below top of casing: ' 40 . • (ft.) • Division of Water Quality,Information Processing Unit;
• gwater level is above Casing,use"+" '. •' . , • , 1611.Mail Service Center,Raleigh,NC 27699-1617.
• l' :
11.Borehole diameter. •••,"..... . • . 4 (in.) 24b.For Infection Wens: In addition to sending the form to the address in 24a
above, also submit a copy of this'foam within 30 days of completion of well
12.Well construct me •
' ion method:: RotarY • . . construction to the following: i
(i.e.auger,rotary,cable,direct push,*0 , ' .• • • i • '
. . .
Division of Water Quality,'Unflerground InjectioliContrig Pipgram,
•FOR WATER SUPPLY WELLS ONLY: ' . 1636 Mail Service Center,Ralligh,NC 27699-1.636
• . • 1 •
13a.Yield(gpm) /el - • Method of test: Blowing-Rig. . 24c.For Water&mph&Iniection WIells: In addition to sending the form to
the address(es). above, also submitione copy of this form,within 30 days of
. •13b.Disinfectitin type
• Chlorine • ' completion of well construction.to the:county health department of the county. ..
: . . - • Amiunti' :.6c) oz.,.
• • where constructed.
Form C1‘1.1 .. . ' .North Carolina Department of Environment and Natural Resources-Division of Water Q1aliity Revised Jan.2013 ,
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