GW1--07432_Well Construction - GW1_20231117

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•• WELL•CONSTRUCTION RECORD •
For Internal Use ONLY: • ' •
.• 17ais form cad 6e used forsingle ar multiple caells . .
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1.We11 Contractor Inforn atioa: . • • . • • •.• • ' • '
�' '
Bobb W. Potts. . . . 14.WATER-ZONES,S.1 • . i. i
PROM. .TO DEBCIUPUON '. .
•
WallConhaotorxamp' it ft I '
30
• NCWC 2028:A • rt y00 rt I I .
•NC Well ConlinetotCertificalzon Number • • 15.OUTERCASJNGUormulfieand*ells)OBLNER6i' ) • •
•
PROM TO DIAA�TER THta3IIrES3 MATEttTAL.
• Ferguson's Well.and Pump, LLC .0
//7 T ( x.5' Z(61)25 PUc5p /
Company Name 16.IIaII�R CASIIalG ORUSING:(gX611tn'mal ducted-laoA) � .
2.Well CouaRnadlon Permit • C#: . :' PROM: TO DIAMETER' THICKNESS MA1 AL 3 • •(w135 ft . • f . in.•
list al/applicable wet(caubrredon pee rein t e.Co'mty,Stale Variance etc.)
3.Well Use(cheek well use)t :
ft• � is
Water Supply.Wen: . : PROM.' TO' : DIAMETER SLOT SIZE THICKNESS MATERIAL .. •
OAgricultutal DMunicipal%Public ft .. ft in '
' . • OCswthetmal•(Heating/Cooling Supply) •lai‘dential Water Supply(single) • ft • •ft • •, • - • •
DIndustrial/Commetaial • .Residential Water S 1&GROUT
uPP1Y( FROM. TO •. MATFRLAI: P24PL ffi�'rMETHODaAMOUNr
.Imptahoa . .'' : . • .. . . .
•Non-Water Supply Wall• • •• . . . .- . . . ' . . • 0: •fc 20 • ft Concrete Gravity-Flow
DMonitoriiig .Recovery. ` [t: . . . .
:Igjection Well: . . ' • . :fr.. ft. . •
' :.Aquifer Recharge.• • • ❑Groundwater Remediation • 19.SAND/GRAVEL PACkff fable) •
CIA. 'er S _ . . .qu>f torag+6 and Recovery;• ❑Sahmty Barer ; FROM To MATERIAL EMPLACEt1�NTMETROD.
•
.Aquifer,Test. . . • • ❑Stomiwater Dtaiaage
.ft' ft •
'DFxperimeatal Technology .Subsidence Control ' ' . • ' . • ' ' ' '
. QGeuthcrmal(Closed Loop) .• .Tracer .• . , PR MDR1•T rnrT .• tads (color,color,hardness,son/rode end,a to die,em) - • .
(,
•
.• OGeotheimal(Heating/Cooling Return) • .Other(explain under#21 Remarks), ,vl• L.ft ,9"0 .it • • ,( tat(. • . .
•
it ft J
. • .4:Date wells)Completed: .1PJ1212 Well M# • q0 //0 • '. .•d d•1 .) ii9l�
•
5a.Well Lecateon:
0/0�` e 't.� •
//7�` `�oft �
Faci(itylOwoeiNamc . • ' • FaeilitylD#(if applicable) f. • ft• .-,r` - ' y'
> Aadnss,city,add zip: n 21,RE11fARK6 . •j�;O V. 1 .7 2023.
Cary Parcel Identification No.(PIN) • ['° 4;c: , •
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees - • •
(ifwell field,one laillong is sufficient) 22:Ce. lion•
•
. '3s 34. t 34464''- ' N $Act, � t.//r l*)G if elf'''.
Ni; r// . .
• . / Srgaatnre of ea Well Conaac r Data.
0.Is(are)theweII(a)::QParmaneat. •
or DTelaporary. •
' • c . .
• :.' 13y slgesng tics jaunt I Ittei'bjr cep,that the weA(s)iras(weer)ceirtslryeted tei aci+ommice •
• with 1SANCAC 02C.0100 or 15ANCAC 02C.0200 Well CwsstrucBaeSlaridmds cowl that'a -
7.Is Ibis arepair teen enisting yell:.' .Yes or •l ia•o .. • . . . • . . 'copy of this secora!hasDeo:pmvtdedtofheWellowner.. .' • . . • . .
• 1fthisis omit*fill cc brown well construction iformmion ono 1esplain the nature ofthe .
• ripair:eider#21Talgiiterssilon or iv;the back,ofddsfovun 23 Site diagram or addaiwnal well details.
• : .•. - ' . • You Ilse the backof page, provide additionalwell .. .may. this page. . •pr vt site details or well. ;
S.Nnmbei of wells constiuct'ed:' - . • ' 'construction details.:You may also attach additional pages if necessary • '
FornwWpkeccaorrnn-wapplyweJZrONLywjhghesmeecgaiwa you cm, .
submit arttfmna SUBT.AI TAL INSTUCTIONS . i
9.total Well depth below land srufact~ '•S'OS (ft.) .24a. For•All'Walls:• Submit this form within 30 days of completion of well
• For multipk wei lief all depols.trdf'emrt.(esmaple-3@200'and2Q100) . ' .: • . ' . construction to'the following: : • i .
10.Static water level below top'of casingi. • . • " .• . (ft.) . • • • Divide*of Water Quality,Information Peaces Unit, .
lfwater level.lsabove censer'use"+" ' ' •1617 Mail Service Center,Raleigh;NC 276999--1617 .
11: •
Borehole diameter.. (n.) 24b.For Inteetion Well= In aidditioalto;sending the form to the address is 24a .
. f i
l�Ota .• above,.also:subunit a.copy.of.this:fo Within.30 days.,,of.completion-of well •
12.Well construction method: . .ry : construction to the following: . .:• 1 .: . .• ... --. •-. - ,
• (ie.;augo,rotary,'cablo,direct push,,etc).
'' • . • . '• . ' . , , , ' ' • . ' ' ' ' • • ' ' ' ' . ' • ' Division of Water.Quality;Un dergeotmd Injecoioli Control Nepali,Nepali,
FOR WATER SUPPLY WELLS ONLY: 1636 Matt Service Center,Raleigh,NC 27699-1636. . '
13a:Yield{gpm) .Blowing'-Rig • 24c.For'Water.Sonply&Ieiethnn Wells'In addition to sending the fours to •. ,
: ••• • : •=:' ''•> moaafte t' . . 9 9
. . :. ..: . . . . . • the.address(es);above, also:sut>init one ocpy of this.form withm.30 days of •
'• 131iDi•- —on' ty •pe:•ChlOnne•: at Ammt: . •iA• • '. .02. . completion of.well construction•to•the,county health department of.the county
where conshpcted.,
• :Form GW-1 . ; North Caroline Department ofEnviroumeat and Natural Resources—Division of Water.Quality� Raviaed but 2013:.