GW1--07437_Well Construction - GW1_20231117

WELL CONSTRUCTION RECORD For InternalUse ONLY: : •
- •: •This form can be used for single or multiple wells ' • - .. i, ••.
1..VVel Coatt3clor Information: .
Bobb 'W. Potts. . . . .• 14.W4TE&ZONES_.:• :' y: i
Y .. .. .. ,
,. . PROM. TO •.• • DFSCRIPSTON
. ;Wel CoattaotorName . , : : ft• ftl .ft • •
NCWC 2028-A :': . . ' • • .. .• � S Oft � i: • • • •• -
.
•
.:NC Welt 15.ODTERCASNG(finsmS oised iella)ORIJNER6fa caBc) -
PROM • TO DIAMEIHR MUCHNESS MATERIAL. .
Ferguson's Well Pump; LLC 0:f. .7A ft. X5'In Z/ , ' ' i7 2/Prrc :
CompaaYName 16INNERCASIIHG'OR G(aeetbetmal %•loop)$ p
- FROM: TO= .� DL111RRTrR' TH1QirTE4S' MATERIAL
' •2.Well.CoaconetonPeinsit#:' .C1` 'Cr3 - he)er-U4k .': • .ft ft ." . `in . .- . . .. .. ,
. •Linauapplicable well ca+isbvedonpensuts ge.Cosvp State,Varimn a ate) • •:,
. ft tt. i>ti
3.Well Use(check well use): : • . • . .
. . . . " : .17.SCREEN•.
Water Supply Well: . . . . . . .: . • . . . . PROM'• TO• ' DIAMETER SLOT SIZE MUCHNESS. MATERIAL : ' .
pakPublic " .ft • ft m.'
•
.. OAgricaltural p � " . . , .
. - DGeothetmal.(Heatingkooling.Supply) • . 'Residential water Supply(single) . ft it . • ' id . • .
• .
pindusteiaUConomercial. .'• . . . OResidentia Su IL GROUT : • . : . -
l WaterPPIy(�� 'FROM TO MATFRJAI.• 1�LACP.affiRf MBIHOD d AMOI1Nf
Mnigatitm •Non-WaterSupply.Well:. . . . . .. 20 Concrete ft. ft oncrete Gravity-Flow
•
. Injection Well: . • . . • . • . '. fp. ft .
OAquifer Recharge...' : '• . OGrouudwater Retaediation•. if 19.SAND/GRAVEL PACK( ippli e) • - , .
M II4�LACEhtSVT
QAquifer St91.4C and Recovery;•
• .. DSalmity Barrier : • - • F. To ; MATERIAL' METAOD:
DAquifer Test. . • OStomtwater Drainage •• .• EG ..
, • :DExpetimental Technology • " DSubsidence Control . GLtl .(attach asbtdtimalsrhatsittterrsaar� ' i' •
. .20.DRrr.r.na
'QGauthet:nal(Closed Loop) : ' OTracer • ' .• :• PROM. TO . •DESLIUPTION cedar,hardness.unfrock tune,rate eft,ere) .
. •,DGcothermal(Heating/Cooliag Return) •• DOther(explain under#21 Remarks) ft. it .
. .4.Date Wel(s)Completed: L, • 'Well JDf! • • ..Ce/ .ft •lip S ft. .• '..SCf/. .S Ft�C'. .- .
• • iin ,,kC1nlrIACS h • . . �' '' . - ft. . �s '. !.t>- %� .. • . • .
ft ft
Facility/Owneriklame . • • . • . • • . • • Facility ID#(if applicable) • .
. -1ha1 Atc.4Arle r � Le1C .S4e�r 741R ft It. �"' . .' t wr ti'=v a 1.• . • .
Physical Addreess,City,•a id Zip :• -• --
2L RE11SAxKS
in('dmbe .: . cir7 j..a 6.3.7�5 3. .. • • . • • • •NOV 1. .�. 707:3 .• - .
. ' .County Parcel ldentifcationNo.(PIN) '
5b.Latitude and Longitude m degrees/nun r decimal degrees: • , .; �,,:;
(ifwell'Sold,one laUiong is sufficient) ntesheronda o 22 Certification: �, ` '�aJ:
f . ...• 5 a. 1/..,'sq1..3fo 11 'DI,. .'h' /%` 1 j Y2 W ..4cr' .l z� . e(„/ C , . • . /? 4i/. A3 . .„
.. • • .
. •Sig • ed Well traetbr. . 1 , . /,• .
., ;6.Is(are):the'4,145).':t etmaneat. or .OTetaporary . si tfsis l : ; .'dio:she wel s-was' ere constructed tit aceoidwsee' . ..
�.Sm►+s f hereby� f) (w 1
. with'ISANCAC 02C.0100 or ISANCAC 02C.0210 Plell•ConctrucfonStrsdrdo and that a
• •• 7.Is this a repair to an existing.well•• Oyes• or o . . .• . • copy of this iewxlhcsr been provided to die well Omni:• - • . . . . ., . ..
Cai'Q ..
•
Vas is a nepdr,fill out known well conndlon 30onna ion and explain the naive ofthe I .
repair ender#21?works:canon;ran de back cf&Islam.. . 23.Site diagram;oradditionalwelldetails.
:: .; / .• . . You may use the back of this page,to.provide additional well site details or well.- : , .
9:Number otwein constructed: ' - / • ' • construction details..You may also attach additional pages if necessary. -
•. Faienddpkfrgeetioiornonwieei Supply wells ONLr with the same construction,you can• :
svbarit cue fern:' ' • . - ,' • . .. . - . . 'SUBMITTAL INSTUCTIONS i'
9.Total well depth below land'surfaee: • ba t, •• (ft.). •24a. For All•Wells: Submit this form within 30 days of completion of well' '
• :F'orosvEOple wssllslM aU.atapths(fdffein0(euaapla=$@200'and aQ . .1o00 . ; ' - . ' .• ;construction to the following: '1: . .; r- - . :
• 10:Static water level below top of casing. . ei/td'• •' . •` (gt.) , • • - Diviiiiin of Water Quality;information Processing Unit, "
:Minterkvel native casing use"+" ' ' 1617 Mail•Service Center,Raleigh,NC 27699-1617 . • •
11:Borehole thew+ r• ,-`• . (m.) 24h.Pojr Irnerhon Welt: In addition to,rending the form to the address in 24a .
ROta . . • 'above,.disci submit a copy.of this:form within.30 days-of completion of well..-.,•. .
• conshnction to the following: :
12.,Well consandion>Yeedtod• : .rY :. •
• (i•c.,auger,rotarY:aabiq chart push,etc.) ' -
Division of Water•Qaalrty,Undergtoimd Injecdon•Cantrol Pengratia,
•.- FOR WATER SUPPLY WELLS ONLY: . . ' • ' • ' . . - . .1636 Mail Service Center;Raleigh,NC 27699-1636.
•• .13i•:Yield(gpm) • • •Me@• .d of test:'Blowing-Rig • 24c.For Water Supply&Iniikiii. We is Iaaddition•to sending the form to. ' . . . .
. ��. .
.. .. the address(es):above, also:submit one l copy of this form within 30 days of• ..
-13b.D sint6tion type:•Chlorine : .• '.• amo�t: . •Ig . ,oz.. . completion of:Well constriction'to the county health department-of the county
where•constructed-
Form EW--l: North CaatlisiDepnraient ofEnyimameat aid Natluat Resources—Division of Water Quality 4 Revised Jan.201.3