GW1--07430_Well Construction - GW1_20231117

WELL CONSTRUCTION RECORD - . . •
' •This form cattle used for single or multiple Wells '. : For Internal Use ONLY:,
' .1.Well Contractor lnformatioa: • - 1 1 ' •
•
Bobby/W. Potts. . 14.W4TERZOI� i.;
Y FROM. TO e r . DFBQtIPTION
Wall CoattreetorName : :
n 5r30 . . .:. .. .
. . . . 15.OUTERCASING(femml&easedwd s)ORLlNER6fkx6le)
..NC Well Contractor Certification Number
. - •' FROM TO DIAMETER THICKNESS MATERIAL: . -
. . • Ferguson's Well and Pump;. LLC • , • '. 0: r - ,1 1s..in' 2./4;
Company.Namc 16.II�1NERCASINGORTU G(meuthetmaldo3edlcop)' //L
', r^ FROM. TO. . DIAMETER ThICKN SB' MA
2.Well Coastiuclion Permit#:. .' da a b o W ft" ft . , �.• . . . . . . . '
List all applicable Well corislrrrc1IOnpmails(Le..Cowt'ty.Slde,Yarimtce etc) , ft. • in. .
I
' 3.Well Use(check well use)i • • • • ' • - •: ' • • • 17.SCREEN ,,
' Water Supply.Well: FROM: TO' DIAMETERSLOT SIZE •TERE NESS MATERIAL .•
• OAgriculturalcipaLPiiblic ' • ' , ft. ft m . •. .. ' . .
. . .
. ClGeothe:mal.(Heating%Cooling Supply) - l sdentiai Water Supply(ogle). • • • tt ft In' '
: OlndustriaUCommercial. • • OResidential Water supp8.GROUT
(shared)
la TO ' MATERLfr: '''EdiPLACE MINT.ME ROD tli AMOUNT
Nonon-WaterSupply.WeU: • . . • . , . . '. .. . . . . 0: ft 20 . fe. Concrete ',' Gravity- low '
OMonitoting . •' ' .ORecovery it: ft
Injection Well: • , ' . :ft ft . : . : .
. ,•. :OAquifer Recharge. ' .' _ ' OGroimdwater Remediation' ' • 19.SAND/GRAVEL PACK fd malleable) ''-
�l�1gl11fer Storage and Recovery ❑Sarni y BatriQ FROM: TO •-: 'MATERIAL,• EDIPL , ,.iSTMETHDD.
OAquifer Test. • . • OStotmwater Drainage , '. . •
• V :OExperimental Technology. ' DSubsidence Control . • , tz • i r
OGeuthermal Closed . •2o.DRrr.r.rNGLOG.(atradraditticoildreetsif> Ward •
( _ . Loop) DTracer. _PROM.' TO .DFSCTtiP1'ION(calor.turdnca,saradt Into.tree die,etc.) •
. 'OGeothermal(ideating/Coiling Return) •• DOther(explam.under#21 Remarksj. . .••f) .ft j l.' •1. ' . . .0,,(�• •• . : . V
• • • ��S .ftSr/litr,1
. .4.Date Well(i)Completed: ( " iO/2).well m# .
• ,wend• tsaan•• • • ' • • ' : • �O. �17 • ' cd/de/C - . . . . . .
r 1/7''� �np ft. ;;Ts"(1W,l7t:
.' Fapility/OwnerName , - • . ' • Facility ID#(if applicable) • ' l '
f.. • ' . ft 1'. "^`�.� ' � '/5 J
ft ft i. . N O l� ,•° •/�
' _ Physca1Addreas,City,'andZip'' 2 BEMARK6 ' . •• ' • , • I 'l 202J •
• jUr- Cr ( . . .. 66; 3/7'41!S : . in•
o n . .
. ' County Parcel Identification No.(PIN) . • L t, .;,� - `:
'Sb.LatitudeandLongitudeindegreeclDamstes/secondsor decimal degrees: ;. • • • .
(if wall field,one latllong is sufficient) 22;Certffieafion:. .
• . •.. .S' 3b :S 9'2i5,� . N.• ,.� ?q? 7(�,
• Signature of j Well Contras
6.Ia(are):the well(s)::C,}Fermanent• or' ,❑Temporary: • • By aigrrng this fotm�I hemby cerl !.dint the wel(s).was.(were)'e.e siraeted(n accordmra
' . with7SANCAC 02C.0100 or 1SANCAC 02C.0200 Well.Cm ceeStmrdmrls and that a
• - • 1.Is this a repair to an'e=isting•well:•' OYee• or ''CdNo •- ' • • ' . .• • • copy of this recordhas been praviekdto the well owner. . . •• ' ' V . .. •
:f this is a rcpdr,fill out known well consauctiontrilivinatIon and explain the nature of the . ' •
' tupdr wider#21'widths spciionoron the backof&Isfann - - ' 23.Site diagram or additional welldetails: '
:: : • : : • :: • : •You may use the back of this page,to.provide additional well site details or well:
B.'Number of wells contracted: • •• •• • ' /' :' construction details.:You may also attach additional.pages if necessary: . :
' •• FarriarUtpk 14ectiai orrwn-worersupply wells ONLY with the setae c.:drat*on, ne '• -' .•• .' . !. • .
submit arefarn SUHI lTTAL'INSTIICITONS
9.Total well depth below land'surface: �. ' • (ft.) .24a. For All'Wells:. Submit'this.form within 30 days of completion of well
.• For nwhfpkrellslislaU.dep/Itsifdfeiort(example- (200'and2(4100) . .-:construction to:the following: . ' . : . :, • • • • ..•.
.10..Static water level below top of rea►ng. • .S ''' (it) _ Divielon-of Water Quality,Information Pruce sing Unit, .
• If.. iwter level Ie above agog sate"+" 1617 Mail Service Center,Raleigh,NC 27699-1617 ' '
11..Borehole diameter: -.. 4. (in.) - • • .24b:.n1r Lrieetinn Welt: In addition to',sending the form to the address'in 24a
Rota .• .above,.also submit a copy of this:fain]Within.30 days:of completion of wen.: .•
::1L.Well construction method:: .ry construction to the following: . : •.i . ...
(i.a:auger,'mtary,cable,direct pusU,etc.) . 4 .
.. . .. . . . . V.
Division of Water t2eiality';Undeigromd Injection Control Prngradr,
FOR WATER SUPPLY WELLS ONLY:. . .' • . • . •• '' .1636 Mill Service Center,Raleigh,NC'27699-1636. • • , - . '
13 a.Yidd(gpm) • M•' ethod of test:'Blowing—Rig , :24c.For Water SsmItly&lniect en." .Wel s In addition to sending the form to .' . : .
the addres(es) above,also:submit one'copy of this,form within 30 days of .
13b iamfection type:
•Chlorine Amoan t: ' . . /. . Oz...'. completion of well,construction'to the county health-department-Of.the county ,
where constructed, ,
•'Feria Ow-1: . Noath CamlinaDepa eat of Envuzinnient nod Natuzal Resoumes—Division of Water Quality ., 'Revised Jan.2013.