GW1--01628_Well Construction - GW1_20240313

WELL CONSTRUCTION BCORI) • • •
This form can teased fat single or multiple wells ; For Intemsl:Use ONLY: '
' • 1.:WelC ContraetoliInformation: . •
14.WATERZONES • .• 1 I .
Bobby'vv . ,P . "
c • FROM ' TO r tON
.: .woll ContmtorName . : . ..
• NCWC 2028 A LS o f t. •
OUTER cnsn�t
:NC Well Coniraetor CcrnficaiionNumber . G wels)ORLiNtIIIfd aupSda6k)
FROM TO. DUMETFtZ TffiCId MATFRiAL.
Ferguson's Welland"P , L umpLC • : • O ft' t i°" /�11�5 pec5p, Z/
Company.Namc •16.INNER CASING ORTURING(geothermal elese tioea), ' ' . ,. a
"2.Well.ConateaetionPermit :. ' •' -1 •" (Q �. �. .• • . . " , . M.ft: .T •• : " ft niA apt . . " . .
FRO O" 1ffiCI�TFS9' MATERIAL
List all applicable well epristnhctlonpeimlLs(re.C.°pity,State,Vartance.etc.) "• . • f� ft • i • ihr.• . • . • '• . " • . •
' . :3.Well•Use(eheck well use)e. . . . . 17 SCREEN. .
Water Supply Well: FROM • TO• niAMEIFR SLOT SIZE .TERCICNESS• MATF12)AL
DAgricultwal Olvlunici " R ft . fri. .
•
lic
' in.
• • 'OGeothetmal,(Heating/CoOling Sipply) 'dential Water SUpp13'(tingle)• ft •ft' •
•. ' •
Olndustriai/Commercial • •• • esideatial Water S 1a GROUT • . •
uPP1X( •FROM.'• ' •TO MATERIAL RI IZL.1C2IentI METHOD AMOUNT
. : Ohrigation
Non Water supply Well 0.• :i` 20 Concrete: Gravity-Flow < •• ,.._,y_,y
OMonitomiitg fc" ft e, t, r L�i V
°Recovery
. Injection Well: fc. • ,ft • :MAW :I ",.
OAguifetRecharge., • " DGroundwater:Remediation'" '. • 19.SAND/GRAVELPA(3 ala
i, ' . ". .. • �
qua S . •
FROM TO MATERIAL. Y2QUCEI1tFNFMETHOD:
°A andRecovery• DSalinity.Barrier - �:u..; „ .ft..
°Aquifer Test • ❑Stommwater Drainage• . '• . • '
oEitper mental Technology DSubsidence Control . • ' h' •
tt 14: •
. •20.DRILLING LOG.(attadL additi�a]sheets ffary) :' .' . .
OGcutheamal(Cluse d Loop) , Tracer ' .. FROM.• TO • .DESt2nPTION calo badness,Mil/rockev 'sale dse,'tam .
OGeothcmial(Heating/CoolingRetean) • ❑Other(explainunder#2]Remarks). . . 0 2 " .'n. n' (a i/" . •• •
,+1.'Date Wen(s)Completed:. Well'IBfi . • •u '. . • . "ft• C °J. f C�. .
y • �� • � Vie "•
5a.WdlLotat ion
.
i- 4 VVAtu.Tn.t ' . .• - .1 "f. . ••ft
. .� t �-�`Gt ct7�
• Faei(ity/Ooy icrName. " 4aeility,lD#(if applicable). " .•
OhP 6" (ILO a v.•
Plwsioal nsess,:aaCity and zip 21: •
oi REMARKti
: 1Visr;,: q'1 l(0 =u�l -�150:7" ..
Co ..
anty Pamellde•ab5o•a6oaN• o•.(PLN) .
Sh.Latitude and Longitude in degreesfminntes/seconds or decimal degrees: Cer t : • '
(ifwrell'field,one lstllong is suHfcient) 22. ca6o•" �
• So,/.5 7, 9Di• N 52°"39' 3 d';�.q�.Z ". w : •
/
Signature of Certi5e6 Well Coatraetnr
:6.Is(arsyhervell(s)::Q�ermanent•"•'•or• :[']Temporary - ' •
• BY super+t 1e form,I hereby certdi.that the well(s)was(were)wee)`consfr ueted in accorelaice "
• wlth'15ANCAC 02C.0100 or 15A NCAC 02C.0200 Well Const►aetlaaStarufa�s and that
• 7.Is this a repair to an&l istin'g well:•" °Yea or •'o�No • •• • • • copy cfthis record has beenpmvtikd to the well owner.•.•• • . ' • .• • .. ..
• :Ifthisis a repair,fill out(glove,well conitmetioie 6forinaion arrdeaplaoe thenobae ofthe •• •
• repair wider#21nemaslaseedonor-on the back ofddsfamra. 23.Sitediagramoradditionalwelldetails: ' •
. .... : : . " nshuation details Youma als tta h additional oral we'll,site details
Youor well
• S.Nombee of wells constructed: ' '• -/' ', co y . P S 'e ssar?: '
•
: .•. For.maltiple bgeettariornan-sdotersitpply wellsONLYwitth the same cwestru on,you can• • •
svbinamefonn SIIBMI'ITAL'INsTUCTIONS
• 9:Total well depth below•land surfacr 70 5 (ft.) 24a. For All Wells Submit this form within 30 days of•completion of well •" .
ForreulQiple wells list ail depths tf�'erens(enartple=[e-mail]2Q100) " conistnictlon to the following:" • 1i .. . ' '
• 10•Static water level below top'of easing'" '• 3(� . : • (ft) •• • •• Division of Water Quality,Information Processing Unit,
If watts revel is above casing use"+" . ' ' " • 1617 Mail Service Center,Raleigh;NC 27699-1617 • " • •
•1 is Borehole diameter. r,- " •(m.) .24b.For Insertion Webs: In addition to sending the form to the address in 24a . .
:above, also submit a:copy.of this fomn within 30 days,of completioce.of well. :
Lt.Weli oonsteadnon method::ROta / • construction to the following: 'j .
(i.e.:auger,rotary;eab!q•direct Push,ate) : •
Division of Water Quality;Una and Injection Control Program, -
FOR WATER SUPPLY WELLS ONLY •, • " ..• ,' • .. 1636 Mail Service Center,Raleigh,NC 27699-1636" - ;
13a.Yield(gpir• • • • Method•of teat: •Blowing=Rig :24c.For Water 8unoly&Intection.Wellt: In addition to seceding the form to
: the•addiess(es)•above,'also;submit one_copy of this;form within 30'clays of"
13h�Disinfection type:;Chlorine : Am„tut: • •
�" Oz• • completion of well construction'to the county health department of the county •
where constructed.
•..Fo;mC9f/-1;" . • NorahCarolinaDepartmentofEnvironmentandNaturalResonrein—Division ofWatajQaal"ity " • :Revtsadlan.2013