GW1--01630_Well Construction - GW1_20240313

. ' .WELL CONSTRUCTION RECORD . • • •: For Intemal Use ONLY: : • . • •1 '
This farm eaube used forsiagle or multiple molls
. 1.;Well Contiuctor Informathon: • • • • • : • : . • : •
' • •Bobby:W. Potts; • • • • • • • • M°•
Tz°xss ': ' D> f ort . ..:
Wall CoatradorNameCf.' ( .�. .
NCWC 2028-A .: . . ' •: . .: a :• • •.: I::: '
NC Well Conhctnr Ceetificafton Number " .
IS.OUTERCA$ING(tarmmifi+�ed la)OBLINffit6i )
FROM TO DLIMFTER THICKNESS MATERIAL'.
Ferguson's Well:and Pump; LLC • " : • •(,) : 7r. vL •I/ ®uc5DZi/:
CompanyNamb 16.INNERCASINGORTUEINGG#at nal'dmed4ouo).
^ •�;� IRtOM TO DIAM 1 R;. THICKNESS' MATERLAL
'2.Wen:ConatructionPerinit#. : . . • .• :-1 dJ . • , . .ft.' • • . . ft. . !' . .to . . ' . . . . . .• • . . " . .• " - " •••
. •'List all applicable well eansovetion permits 1 stogy,State,Varlorxc etc.)
• . • 3.Well.Use(check well use)e . • ' • • ' •
Water Supply Well: •: •
PROM:• TO :•- DIAMETER SLOT SIZE •THICKNESS: MATERIAL
❑Agciouhtrual .❑ . "cipal/Ptiblic it ft ,'..
"' L ❑,Geothermal(Heating/Cooling Supply) • .[?Residential Water Supply•(sue). ' it, ft • . •• m •
Dlndustrial/Comineercial DResidential Water S 10.GROUT . •: • • . : ' •
• uPPly(shared) : . "PROM. '•: •TO ' . . • MATERIAL' EMPLACPMESTMErROD&AMOUNT •
: ❑IaiAation : �,
Non-wirer well: 0 f` 20• . Concrete Gravity Eft y
SbPpl9.
DMomtoring ❑Recovery •it.: ft '.en..�, i., i o'
Injection Well: . • . • . • . • . • . fc•: it • . • ' ` • MAR 1 2074
': :DAquiferRecharge. ': ' ' ' DGrouudwatcrRemediation' • • 19.SAND/GRAVEL PACK Ofinulicabie) " ' . " '
FROM: TO MATERIAL i Et� �.'?. :
17AquiferStorage,andRecovery'" OSalinityBarrier : :" ' •
. . , . .fc fG . . ' . . . Crtt�C�•°�'JC: •'
. DAquiferTest . • . . . OStomtwaterDrainage, : ;' "
• • ; Experimental Technology"" - ' OSubsidence Control • • : • • • • • • • • - • -• • • • ' • • '
2A.DRILLEtGLOG.(attadiadd0malsheetslfne ) '
QGeothainal(Closed Leap) OTniccr FROM .• TO .• , •DES( flON(caer,bardnes scu=Wreck en* m due,cr<a •'
❑Geothermal(Heating/Cooling Return)' .• DOthea(explain under#21 Remarks). • . ' ..•• • , . .
• •
• .4: •Date W•alks)Com• plet•ed•:4Iv l wen •m# • ./•D,fa • •7o • `SGZ /'• S! f1 i(.�• .• •
5a.wanLotation. r
.��7 �rp,�. �(. tip/l is. .: ' . .: • . .• • � m rt t +�G(i u i` fie '
': Facility/OameiNam " ,l" ' . 0 FaoihityW#(ifapplicable) .
ft ft
' . ••MQr lin•14C';1,t_S' jh,Ot"'" a • l I---a'8753' : c ,:"ft" ;
• • Physical Address;'City;'and Zip':• . 21.REMARKS • :
County FauelIdentitioationNo.(PIN)
. • .5b.Latitude and Longitude us degreec/minnteaiseconds or decimal degrees: • •22. •er( cation•. .• '
' . (if well field,onelat/long iiss�suuthc ant) . 2a .•" ,ry • • .•' •
7t1.d/-5•• •/ /OZ7.(87I•rN' �°2J0rf� 7:V�76 ' . w /li r�l ! ;�J , a�� C/
✓ •Sr �ed Well trader :• ; . . . •
!vim : .
.: 'ft..•Is(are). •
thewell(s)::QPermaneit •
.•"or ,OTempors •
ty; :' ' '' '
. .• ,. •. " "By slgtdng this forms I:haeby '.that The well. was•(wen)�eanitructed fir aiomTmra,
with'1.5ANCAC 02C.0100 or 1.5ANCAC 02C.0200 Well:Con tructian Stano'iwds mrdMbt'a .•
. 7.Is this a repair to.>itn'eiieting.wen:. ❑Yes • or •'$1Vo • • " 'copy of this record ties beenpravloud to the well owner.• . ' • . . . • . • • • •
•.{/•this is a rspair,Aff out(mown well consbectlon b�orium m ion andcOla the nature ofthe . `• " • �''•' . • . " , m
repair wader#21•rentoilaysnetios or on the back Otitis fern. , 23.Sitediagramoradditionalwelldeiaiis' .
: • •• You the of thisto provide additional Well •.
� : may use back page pr site details or well �; •
. S.•Nunber of wells constructed. /. • ' '. construction details.:You may also attach additional pages if necessary. •
' ' Fortis:110kitteeNaiornan-water supply wells QNLY,withthesateconsbiudon,yoireai' • • . . • • . •
submit aneferns•' ` SUBRDZTAL INSTUCTIONS ,"
9.Total Well depth below lead anrfaeee " (p ' (ft.) 24a. For AR Wells Submit this"form within 30 days of completion of well. . • •
For wells Nat aN depths,ifdferort.(erampk-3Q20.0'and2Q100') . • ,•:, • ' construction to the following: ' . • ••. .
10 Static water level help*tOP of casinge •'• l.Q " (ft.) Division of Water Quality,Information Processing Unit, • • • •
' ' .(jwalerlevel is abara casing'use +", '. ' ' .1617 Mail Service Curter,Raleigh,'NC 27699.1617 ' " " "" '"
11:Borehole diameter `. • (m.) 24b.For Ini ion'Wells. In addition to sending the form to the address in 24a . " '. •
'(.a. Rota . .• above,.also:submit nopy.of.this:• form within days.of.completion of well.,
• •
12.Well'construction Method: . ry • constretioni to the •
• i •auger en iy cablo,'direct push,.ate)
•. • • • ' Division of Water Quality,Underground Injection Control Program, '
' FOR WATER SUPPLY WELLS ONLY: . • • • • . • ' •, • • • .1636 Mail Service Center,Raleigh,NC 27699-1636. • - ' •
•: 13a:Yreld(gptn) • : :•0•.• " •: Method of •tat: "Blowing-Rig - 24c.For.Water Sulrbiv.&laiecbati Wells:'In addition to sending the foam to •
• • • • • • • the.address(es) above, also:submit one:copy of this.farm within 30 days of.
13b.Disinfection type:•Chlorine . • Amo�,nt• •�'2• oz. completion of,'Well construction,•to•the county health.department.of the county. .-'
where coastrocted., .
• :Form CW-1 : North Cambna DeOgIntentofEnvnnnment and Natcral Resowces—Division of Watar•Quality . •Revised Jan 2013. . . •