GW1--01646_Well Construction - GW1_20240313

. I. i
WELL CONSTRUCTION RECORD • • • For Internal Use'
ONLY: • • • : f . •
This form can be used for single or nmltiple Wells •: , • . • • . ' . • . . . • •
' •1.:Well•ConhactorInformation: . • . ' : .
Bobby W. Potts 14.WATER•ZONES . Dl I " .
Well ContriwtooName.. : ,.:. • . . .
•
NCWC 2028=A .: ,..: • : . . : 1 :f:. . .:: '
ffi f . �
.:NC Well Contactor Certification Number 15.OUTERCABING(for nlfl can d'•we>ta)ORLiN�lfda�B applicable)
. PROM • TO• DIAMETER i • THICSIESS ; MATERIAL .
. Ferguson's Well.and Pump, LLC . ' 0;ft.ca .t` 6,,A;5 �` 2/i,l lr Y1•'cs f)2Zi ,
Company.Name. 16 INNER ORT08ING.( alcased-loop)
MA .
. 2.Well:Consnuctton Perm 'it#: • • • ' &a 3 O) ia . • .- .ft; .- . . ft , D 'in. . . • • . . • • • . - . . . .
THICICriESS MATERIAL
• • List all applicable well caisbnetlon?twit s(la.Cowdy,State,Yar(atce etc. .) • ' I .is • . . . •
• , R ft .
.3.wellUae(checkwellnse)e. . ' ' .: : . .- .. . . • .17.SCREEN.•. , . ' .• -I'. ' . .
Water gap*Well• : ' PROM:• TO• DIAMETER i SLOT SIZE •THICKNESS MATERIAL
❑Agriculnnal: . ./' • • • . . • ❑ eipaUPublic ' . . • , •
• it ft im ;
, ❑Geothermal,(Heating/Cooling Su•pply) ' •,Di esidential Water Supply(single)• . ,ft. ft • . . •,. •_
❑Industtia]/Commataial. ." ❑Residential Water S 1, la GROUT _
• nppy(� . FROM. : TO : ' MATERIAL• EMPLACEMENT METHOD&AMOUR.-_';
: .•,' ohrication . • 0;: ' ft : ft Coltcrete , V Gra - -lod ' t
Non-water Supply.weD: . . . . 20 VItY I lL.�l..r i s z V.a�:D
❑Monitoring ❑Recovery n; to .
"rtc�u � ��` 'I�'YA
• :Injection Welk • . . • ,f•• : . . ft i r, e: L t.1
-•. - ❑Aquifer Recharge . • ' ❑GroundwaterRemediatibn• . 19.SAND/GRAVEL PACK(ifsi lieulde) ,..ei;,a17r^.^.:4,a1rV iS1Sf�
❑Aquifer Storage and Recovery.' • ❑Salinity Baler : .• .. . . .• , . FROM. . ..MArIZtIAL •Ftd r trc ,-..,-rHol� .
`❑Aquifer Test. ' ' • l]Stomiwater Drainage ..
:❑Ekperimeatal Technology . ; ' ❑Subsidence.Control . ' . ' ' '' ' ' • . • '' . a: •
ft ft
20.DRILLING LOG.(atlxh additooal tf' t y)
' •❑Geuthe mal(Ousted Loop) . . ❑Tracer • FROM.• TO .• DESCRIPTION(color,hardness,rolurodt type.Aram Ate,etc) :
. , •DGeotheamal(FIeating/CaoTmgRetran) •' ❑Other(emilein.ueder#!21 Remadtsj. . .' ( ft. .3/J .'ft : (1, y . '. .: .' • . .: • . .
•
/ . .319.ft •.45i.l. tt ' S yrl 5 c .
4.Date Wdl(s)Completed:/'� 94 3,WeIl1D# 0.ft ft .
• sa.Wen'Location.. • IL f
•
l�►��� • • • • ft. ft
• FarilitdOwnerName..jj • • . •
• ' • • Facility lD#'(ifapplicable) . •. • •.f - . . . '
'4"I • ( OuL. Ki..�. ,`. . g/)nR 4 g��8-. :ft: .- _'ft , ' : I'. . '
P I Address,City..and Zip
REMARKS.
f.h..�mhe.. . . . . ' GR8'87667- yemu .. • .
County . . lldentificaoon No,(PIN) . ' •
ngita degreeslminnteslseconds or decimal degrees. . •
�"b.Y.atitnde and Lo '' de is '
(if dtell Seld,une'Jatllong is suffiaierit)
22.•CertiScatioa:. .:
t /j 1
.3y $- k/S51 • N' ,I Aa'y ) L9'3 32 . w /Grp V/.,eA, . 74su ,. •
SiBoC ' eel Wenactor. . ' Date
: .6.Li(are)the ivell(s)::[3Permaumt-• or .❑Temporary: . .
B3'stgrriirg tins tome,Ihereby ! thg weA(s)was(wero)catstrrreted id accwdmra
with C 200 Plot 1
•• ' 7.Ice tMa a repair to an misting Welk••` ❑Yes or -'61Qo' • •. ' • copy of thisrizcorrlhasbbeenprovidedto the2weRoKmer.. .• '' .. • i • • . . . •• •
oa Stattdmris and a
'Ifthis it a mpatr,fill etaloiown well oorubrrction bfcrrndion and erplaar thenatrwe ofthe - '
• r+epair,rmder#21 rrmaiiasectiar or-on the back ofthiefoarrs , • 23.Site diagram oradditional well details: . • • .
• • • ' • / • . •You may.nse the back of this page;to.provide additional well site detail,s or well, • . .
'Ie.Number of wells oonstiueted: : ' •. ' ' .I • • construction details.;You'may also attach additional pages if notes uy:
. Formuldpk6feet#anornon-wateisypplywelk mar with d wane ctt,youcai• : • • • b C i.. • .
submit atmfonrr' SUBMITI'ALIN'TUTIONS
,
9.Total well depth below'land•surface ' q/?9 .. • (fn). .24a. For All Vella:' ,Submit this,form within 30 days of'completion Of well
• . For multiple wells Pat al.deplhs,tfdilijerwt(ecmnpler.3@200'ioui2@1000 . .construction to the following: •• . ,I,• : . ' ..'. . . . . . . .
.10:Static water lesvel below top of casing . , 7 . .. . • . °.'(it.) - : •. Division of Water Quality,Information Processing Unit, .•. . :
' '.If water level is abaue iastng use"+•• ` •' . 1617 Mail Service Center,Raleigh,NC 27699-1617 .
11:•Boraehole di•ameter: (ae.)' .24h F'or Lnieatinn Welke In addition to sending the form to the address in 24a
• . . . . . RO,fa :above,.also subunit a_copy of.this'form within 30 days of.,completion.of well.',
- ctmsftuction to the folloUing. d
. . ' �L2..Well conatrudioa Method: : rY:•,' • • • • . . • - .
' (i.e.-evger,•rotary,Cable,directp'nsb,ate.) • . .
' Division of Water.Quality,Underground Injection Control Pangrasu,
• . ' FOR WATER SUPPLY WELLS ONLY:•. , • . •. ' • . ' 1636 Mail Service(tenter,RaleigDh,NC 276994.636. .. . '
13a:Yield(gpm) ' 'c . . • ALe od of tesh. Blowing-Rig : 24.For water Sumac&Inieition.Wel s:'In'addition sealing the• ,foma to .• : .
, . . .• . . ' ... . . the-addresses)above, also• submit one}copy of this firm within 30 days of • .
13k Dittinfec.on• type: Chlorine. .Amu®h• q(i . . •oz. completion of:well construction to the county health depart ent of the county
where constructed. •
•
: FormOW--1: -, , North Caiohnal)cpartmcntofEnvironnicntandNaturiil Resouzces—Drvision of Water Quality' • Revised Jan.2013, •.