GW1--01634_Well Construction - GW1_20240313

WELL CONSTRUCTION RECORD '. For Internal Use ONLY . ' . ' .
Ttiis form eau be used forsing�e or multiple areas
1.Well Contractor
Conttar Infornoation: • : • •
: 14.WATERZONES,..• . .:i - .
Bobby W. Potts .
FROM TO • • r' 'DESCRIPTION • '
• ,: ;Wail CoattartorNnme'. : . . . • . . ', •
ft ��� it •
NCWC 2028 A f •zt 'I ..
• . .:NCWellCoalactorCertificstionNumber . . 15.OtTPERCASING(far mnlflaa.ed edla)ORLlNERCd 1 •• • .
FROM - • TO• DIAMETER • THICKNESS MATERIAL'• , .
• ; . : Ferguson's Welland Pump, LLC . '. •. 0: : ft t;,?..SIn 2/4 S Pve,_gi,P/ .'
Compuay.•Nam•c • • • • • • •• itnineRCAsemoRTOBING(:peodarnialiibeed . •.
PROM' TO DIAlItETER THICl�iF88' MATFRW.
L VPen:Ceaaanetima Permit#:. • .D S S. 7". o a 3.L l 4.1S • . .•.R' . . . . ft • . . 1 . .ia.. . . . . . . . • .
.•'Listatt appi cable Mel cdisbrrctIon pgni8ls(le.cowdy,SYde,Yorianc4 etc.) ' . in: . .
: :3..7a1.11 se(tlteeltwellt se)e. ., .: . 1
• Water Supply Well; FROM:• TO DIAMETER •SLOT SIZE •TBICENFSS MATERIAL .'
OAgriculttual
. • OGeothemtal.(Heating/Cooling Supply) • • ater Supply(single) • . • ft ft •. ' . is .' . '
: oIndusttial/Commetcial. , , . • OResidential Water Suonly(shared) .; is GROOT TO • MATERIAL. . FaPi.aCIDATIrMETHOD a.AMotarr•
OhsiRatia�n . .
0 it 20 . rt Concrete Gravity-Flow
iron w:ite>•Sbpply.wen: • ' . . ' . .
•OMonitoting . •. . . ' ,ORecov ft. .ft. . • - . • r' ;�" -
• ; . .Injection Well: • . it ft ti :L2 i
:DAquifer Recharge : ' • GT •• Ooundwater Remediadon••' ' 19.SAND/GRAVEL PACK(if ap e) EBdF3
• • •.i
D
O
DAquifer Storage addRecoveiy. f Salinity Barrier : D
FR M TO MATERIAL .ACE[I�iiT4�jtL)
OA et Test •
quit OStoaonwaterDrainage ltt�r.,,,' ;, �.,.
fc G' Ci:Z. �a;,, ;.J .JC .
• . :OExpctimcntal Technology • - • OSubsidencc Control '�'�'- = P:
20.DRILLING LOG.(attach itd�sheets iinmeass)
:.• OGeuthenna((Closed Loup) • . ' . . OTrat er : .. FROM . TO 13ESLItIPTIONicolor,hardness,deal ow,pain due,ere) •'
•' •OGeotiteimal(Heating/Cooling Rewzu) •'OOther(explain wider#21 Retaadrs). . . • . . i e A L/•• • •
.�? ft �D •t
4:Date Wen(a)Completed: • '. 3 ft• • ..' I.5,0. /_' .
/ �i/213 .%MID! : d
�.. eII Loatton: ; . . R it -: " i' (ti-l'd i O i t,,,(C : .
�y� BYO
. . '�A,4�• and ' 1der�WC.- • ft . . cc. .1: .;. .. .. . .
Facility/Osva(Name Facility Mii(ifapplicablcj . ' . - I . . .
. .tz it
(Lei LGtt.lry reLlitiuit(0: '87go,,. . . . ft. i. .-. . S.lit. :
Physical Address;City,and Zip
- 2LREMABKB.
(-le.viecrSon bk.(3 O5. 3 • • ;.
County : Parcel Identification No.(P/N) .
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees
(;fate 1 fia4.imo l iatoiig is,s�icient) 22.Ceruueatio•:.
•'3S'A/' 4,0t N' 1'x.? t.7,
010 w / / .
Y
. . Signature of Certi5 ell tractor .J. Date .
: 6..Is(an):hewadl(s)::KPertaaneat'. or' .DTrnrporary' • • . Ey sigmbtg tfiis form,Vinci;oere);.that'th .weU(s)was(were)carcshncted ni acewdarax .
• with ISA'NCAC 02C.0100 or 15ANCAC 02C.0200 Well CoriOnta ceStwidmris and thdt'a•
• . . 7.Is this a repair to:an existing well:• OYes; •or •[moo. -' ' . . . . ' .. copy offids record ha been pro*"to the well owner - ' ' . . . . • . . .• ' . . '-.
. •Ijthisis a nepar,fill out(town well cor�chionbfonnation and explain the natroe of the . L'- .
' >epair:Dicier VI.retosiltsstotionoron the back.of thisfwrn. • 23:Sitediagramoradditionalwvelldetailsi
:. : : .. - . :.. . •' . •. .'. . . . , : :You may Use the back of this page.to provide additional well site�ir.tails.or well.• '. "
S.Number of wells constructed: • •• • construction details.:You may also attach additional pages if necessary.
Forriatldple bpectrori erne►,-watersypply wells ONLYwith the saaaeo autrrct o,yaw can ,. •.. • . -
subndrwufons • • SUBMITTAL INSTUCTIONS. •• -
' 0.Total well depth below land surface: .2'yD M.) 24a. for All'Wells: Submit this.fotai,within 30 days of bompletion of well
. ' ,•Formuth*.welLrlist al daptre ifdOErivu.(esmrgple-3W O'ard2®100') ." . constmctioa to the I liowiag: . . I. .". . . .
• ; 10.Static water level below top of casing.' . '2.O . r''.(ft) DIvisIDn of Water Qualtty,Information Processing Unit, . .
If tiaterlevel is-above cashi'rise"+"' • " 1617 Mail Service Center,Raleigh,NC 27699-1617 , '
11:Borehole diameter:: .`d : - . ;(in.) • 24b.Por Toterhon'wallin in add hod to sending the fora;to the address is 24a . .
• Rota • above, also:submit a.copy.of.this,'farm with.* 30,days.of.completion of well.' :.....
: 12.Well:eotiattuctioa method: . U :' enostrnation to the follooting; . . .
(i.a•trugo,rotary cable,direct push,.etc.). •
'- .' - ' Division'of Water wanty,'Undergrouod Injection Control Progratai, '
. - FOR WATER SUPPLY WELLS ONLY: . ' ' - '` . •' . • . • ' • 1636 Mate Service Center,Raldgh,NC 27699-1636 . • ,, • ' - • '
0 •
13a Yield(arm) • 3' McBioa of teit: •Blowing-Rig • ; 24c.For Water Smtply&htiectiati wells: Ia addition tosendmg the fomr to .
. . . .• . ..: . •
-- . . the•address(es)..above, also:submit one:copy of this.form within.30 days:of..
• • 131.Diainfecbion type:'Chlorine •- . A>mtme:. - 'A.y -• 6z • completion of Well.construction.'to•the county health.department•of the county' '- .
•. -where constructed..
Form GW-1.: : .: . . . North Carolina Department of Environment and Natural Resources—Division of Water Quality RevisedIan.2013, .:.
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