HomeMy WebLinkAboutGW1--07436_Well Construction - GW1_20231117 r
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. WELL CONSTRUCTION RECORD ForInternalUse ONLY: ' ,'
This fatal can be used for single or multiple wells • • • ' .
1.Well'Contiactor Information: •
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Bobby:W. Potts. . . . • . . 14.WATERZONES_-.• . .1 ..
FROM- TO 'DFBCRIPTION
• : ;Wel Coa• t ador• Name-.: :• . .:. •• .fe 00 . . • - I I:
• NCWC 2028;A ;:: . . ,:: • • • r* rt
NC Well Contactor Certification Number '15.ODTERCASNG(for mnllicasedweDa)OR LINER. (f ) .
. ' FROM TO• DIAMLrfER Tffil3tNFffi MATERIAL
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Ferguson's Welland Pump;, LLC • 11.` : 3%.ft • C c:�,Stn. 2l-IP I. Po s p 2/
CompacyName • • r •• • • • • • • • • • • • 16.INNER CASE(GOR TUBING( amediaot).
•2.Well Coastnietiont Permit#:. •Z 3. -.D Do q.:1p : . • . ft • �
. • List all applicable well cOstructionpartidts(le.Cowdy,State,Yaia ce,ate) ' • ft' ft . ' .m•
3.Well Use(chuck well use)t • . •• 17.SCREIItT.
. . Wader. Supply.Well: •. . . •: . .• FROM: TO DIAMETER+, BLOT SIZE T1Bt]I? MATERIAL
• . . DAgricnittnal '. ' '
' • • OGeothetmal,(H� ug/Coolig Supply) de ibal Water Supply(single) ,ft'ft m .' - . •
Dlndustrial/Cctomergial DResidential Water Supply.(shared) . 18'GROUT TO : • . MATERIAL. '' FMPLAcERIENTMttlHODaAMOUNT
•. .•' OTtiipaitian .. .: . . . . . . '
Non Water Supply.Wd1: . . • C : tY
...ft.. 20 ft Concrete''' Gra4i -Flow
oMonitotiug DRecovery
t<.• ft
Igiection Welk fa ft
'. •• :OAquifer Rccbarge.' •• • DGrouadwaterRemediation' • 19.SAND/GRAVEL PACK(if inallealde) • • • •. •
DAquiferStotage_atidRecovely .;: GtiTityBalrier.•' • . . . TOMATERIALimmix).- .
• FROM •
R ft
- DAquifer.Test. . . • . . • DStomiwater Drainage . ' - .
. •:DlStperimental Technology DSubsidence Control
rrr.Inr LOG.(atitiemlaiflsl
l7Geothetitlah(Closed L•eop) :• ' DTraecr ' . - . :• FRoM • TO .• .DFSLIEPTTON t larch rdUrack type,entn use,ete] .• ' •
•OGeothesmal(Heating/Cooling Rattan •• DOther(eatplain under#21 Rematics). . • a.ft• A S .ft - •
' 4.Data Wel(s)Completed:I/f .3 ' WellIDfl S •ft 6 :S y(5*tom•
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Se.Well.Location: ' 3�1 �5 :f. . .•• s,grl�f�•.
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- c " 7®s PtteC•i;ur,Tf'
FaeilitjOwaeiName. ,- • Facility DM(if applicable) _ • - -.
. .: ..1-11' roO Ma( : r: • 1 eeS'ter o'�g7gt rt- • ft N. . • ` •
Physical' City,and Zip• / L
1t iC
U. ' " t: . . RGQQ t53105 ,.��.
County • . Parcel Identification No.(PIN) :�,>i. `' _ . .
Sb.Latitude and Longitude in deignieslueloutetheconds or decimal degrees: •
(ifwon'$eld,owi 1suij is saffieient) 22•Ce ti i.
•.... IS. °3.S� 5�.� y�N •`d-L iD d 37 ‘6,'0 W �/
• . . •Sr of eel W • tractdr :
6 Ya(ara)'tha�vall(a)::OPortnapeat• ar aparar .. tads 1 haze by that the well(s)vas do canslritcted in oceordmice
• form, . or! NCAC 02C:0200,Well ca ueNan SYardmps and that a
• 7SANCAC 02C 0100
•• 7.Is this a repair toan'esisting•weil:• DYes• or E o • • . • . • copyqfthisrecordhasbeenpmvimdtothe.wellowner.. . . . • • .•
• . •:f this is a nepatr,jilt ant lowwn well eonroruwhon n ommionandetplan,thena1we of the -
repair under#21remain section gran the back,of this feints. , 23.Sittediagramoradditionalwelldetails:
: You may,use the back of this page..to;provide additional well site details or well •• ••
8.Nttmber of wells constructed: ( construction details.;You may also attach additional.pages if necessary:
FormuWple b eetio sor, s-water supply wells ONLY,with the saneccpsYradioa,you • • . •
submit auefan& S(IB11IITrAL)NSTUCTIONS .
9:Total well depth below land'surface: dS • (ft.) .24a. For All Wells Submit this,form,within 30 days of completion of well
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. For.narltlple wells list all.depdis(JdilVelt Cezanple- . 00'aad2@1007 . • :. . . .• construction to the following ,, .• -
'- 10...Static water level below top of casing S t„1 . • • • . (ft) • • Division-of Water Quality;Information Processing Unit,
.• Iwater level is above cash ace"+ . ' ' ' • - . ' 1617 Mail Service Center,Raleigh;NC 27699-1617 ' '
• . 11:Borehole dia*+PoPr: f` • • .(ia)' . ; • ' . • 24E.For Inieetmon Welle In addition to sending the form to the a i ddress n 24a .
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. . . . . . . . ROf • :above, also submit'a,Copy.or this:fortis within.30 days of completion.of well. : . .•.
: 12..Well construdion meth aod: . .ry . construction to the following: .•• ,
(i.e.:auger rotsr,K. b1 di<ectpush.eto•)- . . ••
' . ' . . . . . Division of Water.Qdality;Un rgratmd Injection Control Program, -•
. de'
' FOR WATER SUPPLY WELLS ONLY: . •. - •. • 1636 Mail Service Center,Raleigh,NC 27699-1636. • . • • ••
113a (gp • • Method of test: 9' g- Blowing-Rig 2a-For Water Smbly&Iniectioa.Wells: In'addition to sending the•form to.
.Ytdd
... . , the addiess(es)above, also:submit one copy of this form within.30-days of
• . 13b.Diamfectiun types Anoint • S • • oZ. •Chlorine. completion-of:Well constriction'to the county•health•departnint of the county
whereponsavcteat •.
... Form CW-I : . , • • : North:Carolina Department of Environmentand Natural Resources—Division of Water Qoalt Revised Ian.2013 •