GW1--01631_Well Construction - GW1_20240313

•
.
wl4LL'Cl/Li ItEt.i.11(110 '. • • FoInte'malUseONLY: • ,
• . • :This form can be used for single or multiple wells. .
•
. 1.Well ContsRctor Information:
• Bobby:W. Potts' .. . . . • • PROM
DESCRIPTION.
•Well ConhactorName - . ft. /eh. h . .I I .
8 • '. . •.30: .
• NCWC 202 =A . . . ft: ? tit.
•
NC Wen.ContraetocCeititcationNumber : 1S.OUTER CASING(for mulflatsedwds)ORLlNER(if • )
FROM" TO " ' DIAMETER 'THICKNESS'' MATERIAL
• • Ferguson's Well,and Pump, LLC . ®,f� /,fin' �y, '� //i� ' •f l'c.s . ,/ •• •
Company Name 16.INNER CASTING ORTUBING( mat dosed ono)
A
. 503 �.
FROM TO DL1MErER THICKNESS• MATERL►L'
• 2.Well Construction Permit#:. •ft . ft in. .
List all applicable well penis(i s County,Slate,'dodance,etc)''
3:Well Use(check well use): ''
f.; ft i is
• . 17.SCREEN .
Water Su Well:. TO .
PPIy . •FROM • .DIAMETEtt. SLOT SIZE' THICK@1FS3 •MATERIAL
.0Geothetm (Heating/Cooling Supply) esidential Water
tit t m
in
Supply(single) ft t •
Olndustrial/Commeicial • • • DResidential Water SuPPh'.(har s 1&GROUT • -
: FROM TO • MATEttiAL: " Eb4PLACEIIffiHTMEfHOD at AMOUNT •
❑Iaigatioa ft* . ft .Concrete Gravity:FIOw
Nna WatersuPPly Weu:: '• ' -
❑Monitoring•• ❑Recovery. . •
Injection well: .• .• • ft . • •ft. • . •i Mud•J `'' •
❑Aquifer.Recharge' : : , .:, : . DGroundwaterRemediation ,•. • 19°SAND/GRAVEL-PACKdrapeieeble) •: •
'. . QZ9 •
: • ❑A er Storage and Recovery Berri' FROM TO MATERIAL EMPLACE ENTMECHOD
�.. g .�•J�� • ,�Salmity �ir ' t� � 3 :l'i':.i::':�A��Hr:�X
DV oi'§t7r '
'. .❑Aquifer Test ❑Sto�iwater Drainage - .. . '.
•
ft ft
❑Experimental Technology 'OSubsidence Control f
• 20.DRILLING LOG.(attach add hanal sheers ifnmrsvary)
• l7Geuthernial(Closet'•L•uup') • ❑Tracer • ' FROM. .TO DESC°R1PflON(color,hardness,soil/rock type,gteln Are,eta) '
❑Geo rm theal(Heating/Cooling'Return) -'❑Other(explain under#21 Remarks)- ft tit -
•
•
• 4. •Date.Well(s)'Completed: /f—'•.. Well ID# . • . • ft.--
t- 60 tit • :s
( fie
�ft
:5ar wen Location: 9� /fogJ •e r
/pot: 3(6- tit , • .
t
Q
Facility Name / .: Facility IDS(if applicable)
•8113a (1 i ;rJ ft• :, tit
Physical Address,City,and Zip.. :.
21:RE11fARis^S'- . .
b
County Parcel IdentifcationNo.(PIN)
SSb.-Latitude and Longitude to degiees/minutes/seconds or decimal degrees:
(if well field,one Lit/loag is sufficient) 2 2.CertifiK' , ' •,
' Sr o Well Con tot D
6.Is(arti)the WCD(a):; rut •ur .PTemporary
By.sigrdng tics flirty;1"hereby oerlify'that,the weA(s)ivas(were)constructed in accordmrce. . ..
with.iSA NCAC 02C.01t70 or ISANCAC 02C.0200 Well Construction Standards-arid that a
7.Is this a repair to an existing well: ❑Yes or • QNo • . • copy of this record has been provided to ire well owner: • .
• • Ifthis is a repair,JAl out kn,ownwell construction irfonnation and erplahi the native.ofthe
•'repair corder#21 rents*section or on the back of thisfomr. . • '23,Site.diagram or additional well details: . . ' • •• • . '
• • You may use the back of this page to provide additional well site details or well • •
. ' • S Number of wells constructed:,• : ' •. . •• ' . ' . • : ' . •: . . construction details. You may also attach additional pages'if necessary:
Fornarhiple infectlotiornon-water-supply wells ONLYwith the same construction,you can.:'
subnct ivrefornc SUBm TTAL INSTUCTIONS • .
9..Total well depth below land surface: •• 45 ' (ft.) •24a. For MI Wells: Submit this'form within 30 days•of completion of well ' • . ' '
For»arUipk,wells list all depths if diffe ent(example-3@200'and2Q100') construction to the following:• •
•' . • 10..Static water level below top'of casing: . y • Division of Water Qnality�Information'Pro. Unit, •
• 1f water.level is above ecsbrg,use"+" ' ' • : : (ft.)' 1617 Mail Service Center,Raleigh,NC.27699-1617 • . .
•11,Borehole diameter: ' . `Q (im)- 2 d 4b:For lniection Werra: in adition to'sanding the form to the address is 24a '•
ry
• Rota . above, also;submit a copy of this:form within 30 days'of completion of well . • -
-: 12.Well otinstructionmethod: . ': •
' ' :c,onstructiun to the following :: :
. • (i.e.auger,:'rotary,.cable direct push,etc.) ' . • . . . .• '
d
'Division
of Water Quality,Underground 1m ectioe'Control Ptaogeam,
FOR WATER SUPPLY WELLS ONLY:. . , ':. • . . 1636 Mail Service Center,Raleigh,NC 27699-1636 .:
. fi
13a.Yield:(gpin '• 0 0 Method,of test
Blowing-Rig 24e For Water Santo&%. iction Wells: To addition to sending the form•to•
th• e address(es)above, also submit one copy of this form:within 30 days,of. • :'
• • Chlorine • etO oz. :. completion of well construction:.to the:county health department•of the county: •
13b Disinfection type: Amounts where constricted.' . . . . • '. • .• •
.
Form C W-1 . North Carolina Department Environment and Natural Resources—Division of Water Quality • • Revised Jan.2013