GW1--07434_Well Construction - GW1_20231117

' WELL CONSTRUCTION.RECORD ' • ' For Internal Use ONLY: !:
This form can be used for single or multiple wells .
• .1.Well'Contractorinfornoation: . - : . • .
•
Bobby'W. Potts 14.WATER ZONES_ :• . is i .
• •BROM .TO .`• r. 'DESCRIPTION . ' . •
-:Weil ContactorMins •: • : . : : : • : . . •ft ,O ft
NCWC 2028-A ::. • ':. • 7/(7: ht f .: . .. . : . .:' • .
NC WellContiactorCett>ficalionNumber . . . . •. .1S.OUTERCASJNG(formni6•eased�s)ORLENFRtfappl3nde) •• •
• • ' FROM ..- TO• - DIAME= • THICKNESS .MATERIAL. • '
, Ferguson's Welland_Pump;_ LLC - • (91 /O S.f . (ot r" z/(r ..s-: /iec)� t./.
• Company.Name : ' : : " ' : '16.INNER CASING ORTUBING.(tmeotbermal daeed400p)'• : •"
. - , . .a• h PROMTO • • . .T�
Zwaa:ConslimetIDSIPESLlit#:. . a Oa• : n ...ft..
ft DIAMETER. . .. .. MATERIAL
•'List alIamhea6le well caratrucrtonpemrtts(ie..Cotmty,State,Varmnce,et.) . . • t '. .
' . " .3.Well Use(Check welluse)t . • • . • . .
f � i
water Supply Well, FROM' TO- DIAMETER .SLOT SIZE THICKNESS MATERIAL
❑Agticultutal' .". . . " . . ❑CVbF��lic . . . .. . . ' . . •
OGeothennal(Heating/Cooling Supply) esidential•Water Supply(single), . • ' ft . it' 'ill.
.
" "❑Industtial/Commetcial ❑Residential Water S is.GROUT ' " , • . - :- . . '
Supply.(�� 'FROM -.co .MATERIAL F1�LxCEbffiVTMETHOD&AMOLI[t!'.
.
❑hrigatioa 0 ' •.ft 20 ' •. ft Concrete:• .Gravity-Flow
waterSapply.we»: • . "
. ❑Monitoring . . . " _❑Recovery - ft' • . • ft . •••'' . • . . . • • • '• . •
Injection well• fc- ft
- " :❑Aquifer Recharge..: : OGrbuad�vater"Remediation . . : 19.SAND/GRAVEL PACK Ctf iao lcsble)
` .❑Aquifer Stor• age and Recovery ' ,. D Sanity larrier ; ' , PROM: TO :MATERIAL•, F110+LACF11�1T METHOD
. '❑Aquifer Test, . • . OStormwater Drainage ..
• . :❑Experimental Technology • OSubsidence Control : " tt — r. •
QGa,tkontal'(Closedl.uop) ❑Trauer PROM . TO .DES oONNe(edar,bantarss.sd:no&VW.!Muoma.rc�
. ( ,
• `, DGeothenaal(Heating/Cooling Reams OOther(explain under#21 Remarks) . .:("1. .!ti ..7 5 • 'cloy
. .
L it ./�
4.Date WeR(s)Completed:/�/`!!�3 ",Welt m# • J
.WdlLocotioa: . : : . (V ' n fVS H .• :- I C.4/CDC/"L.
'"�` 1/AS ft . : (�rCtt.'d • :
r I P" M Srtie��
Fac4ity/OwcerName . FamhtylD#(ifapplcable) "
-ft. ft Tz`--' `'_ y
VQ i;/ nx_ 611._ A 40 utl(o••,-'9-80.0c, • ft. ft' • • • • .
. .-, Physical Address;"City,and Zip. ,.
Z.REMARKS 7 Q 2 3 •,c� t.(rG . • . 2 LJ
t.ln�c)rr)bc�� �((�l l'a. '
County ' • • • ' • Paraclldentification o.(PIN) . - Ins'c c P` ^s.7., .
S6•Latitude and Longitude in degrees/n inutes/ceconds or decimal degrees:
(if well field,one 1sNoag issumctentj 22.CertiSeati :.
• S c�4 lye, `l� `rN-• F� l O/0. ''7e Y`' . w. . .
. . .�1, ; .:" � ; . .
) 04natere o WS'Contractor .
. 6."Is(arethewels:: ; ermneat. or" •❑Temporary . • 'By signingldslbm,I•hereby ce+ty. u the wilier)was(were)ca isirrrctid to aoeorda ce
with ISA NCAC 02C•0100 or ISA NCAC 02C•0230 Well Consiructioa3tcouler tr and that'a .
7.Is this a repair to"an esisting.wen: • ❑Yes "or " GNu ." • • • . . 'copy oftlesrecordi:r beenprovlthdto dre'well awner.. .• . . . . - " . . .
. "Iftlds is argil's,fill oat Mown pol coostrucllon ofoniudton cod explain thenatu a of the • • - .
• repair wider#21 remakes anon oronthe back of thisfoim. . - 23.Site'diagram or additional well details: "
• ' '.. f'_ : You may use the back of this page•to,provide additional well site details or well
S.Number of wells constiucted. • / • construction details.;You may also attach additional pages if necessary. '
• ForrinuWpkbgeettoriarr ors-widersyypplywellsONLYwih the same cciygrgc*on,youcin'. AL . . i'
submit aiefonn cc�� SUB JZT INSTUCTlONS .
9.Total well depth below land surface: '• 7 IA..7' (ft.) 24a. Flit;r AR Wells: Submit this"form within 30 days'of completion of well' " .
:For wells list all depths,tfdi ervtt(eivanpla 3@200'and 2@100') . . . , , construction to the following: . - . : . . • . ' ,• . . . .• . " . . . •.
' 10."Static water level below top of caring. • . /..0 I'• (gt) . Division of Water Quality,Wormation Procesefag Unit, ; . ,
' • • If wares level leabave carat;use"+"' ' . . • - , •1617 Mail Service Center,Raleigh,NC 27699-1617 '
11:Borehole ilian•et.+r 'f y . •(in.) . 24b.For Inieetion Wells la addition'to'sending the form to'the address'in 24a •
• • • • • • • • • above, also' a.copy of this within.30 days,of.completion.of well. . . .-. .
iZ Well construction method: Rotary.: ' • . •• construction to the following: . . f' . • ,
(i.e.auger,rotary,table,'directpitsb,.etc.). •• "
Dlvialoa of Water�lity,Undergrorond)iajccotog Coatiol Pcograru,
FOR WATER SUPPLY WELLS ONLY: • .. 1636 Mail Service Center,Raleigh,NC 27699-1636
13a:Yield(gem) Blowin Rig ' . 24c.For Water Supply:&lniectina Wells: In addition to sending the form to . .•. . " . -
j' 5• •:: Methodoftest g . 9 •. . ... 't one copy o thm 30 days,of. .. :.. . . . . the addresses above, also.submm t this form wt
13b.Disinfectiontype:-Chlorine-: Amooat- .oz. . co lett 000 well construction to,the;County-health department.of the county" • • ' .
:Form CW 1,: . North Carolina Department of SaVimament andNantri Resowees,-Division of Water.Quah Revised Jan.2013, ,: