GW1--01650_Well Construction - GW1_20240313

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For IntemalUse ONLY: {
This fens can 6e used for single or multiple wells : . • • • • .
: • 1.:Weil Contractorinfornsation: • • • • • • : .-.
: Bobby W.•PoftS .: 14.WA TEB ZONBS_ r DFSCRD+ITON
Well CoabactorName • • • . , •, • , - - : ft
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-. :"'NCWC•2028-A' tz f • �, F. ' NCWeli.ContnistorCertiticalionNnmber:: • . . ' 1S.OUTERCASING(for mniticnedw dis)ORLINER6f )- ..
.: FROM .: TO ,: DMIdETER THICKNESS .' MATERIAL
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Ferguson's Well'and Pump,.LLC • • ' ' • ' . .0. .rt. g . ag. 5In''A/poi/aS. eve5—..Ri2.2i ,
:: .CompanyName.' . • .. • : .16.INNERCASINGORTUBING( mal'daseddo0D): • .
•' '� - , PROM .TO DIAMdSIER• THICKNF93' MATERIAL
L Well Consiination Peimit#l: 2 0 Z 3.- 0030,0 . • '.ft. • ft. : ' -a,, m,. . - • •
List all applicable well cmesnitcdon pemdts(1'e.Comply,State,Var pea eta) ,: " ' '
. rt ..ft.:' �; :;a
3.Well Use(check well ase):
17.'SCREEN
Water Supply WcHt ; , • . ' . . PROM • : TO . . •DIAMETER I .SLOT EZE -THICKNESS MATERIAL '• •
OAgiiculttu=1.: :•':'
;: .:.0 fic . ft • .ft, '. um,. • . .
. DGeotheamal(Heating/Cooling Supply) O Water Supply(single) ' . • ft tt' in'I
18.GROUT
. OTndusttial/Commencial ❑Residential Water Supply(shared) : . FROM . . . TO . . . . MATERIAL FAlpL CEt�►N!METHOD a AMOTnvr❑Irrigation. . .
Non Water Supply well::' • 0 :•fa 20:•: :Concrete .• Gravity-Flow : . •. - '
M Oonited:*•• . . . . 'pRecovery . • . • .. • . ' . . ft '
•' ft -.. . . . . . .cy . .
Injection Well: • • • .' ft - • ft' •
,i. '4•L• • L.L,'R• ,. F� '.
❑Aquifer Recharge •••••. ElGroimdwater Remediation : •19.SAND/GRAVEL PACK(if malleaHe) J( .
: ❑A •$ and Reco • • FROM• TO .MATERIAL .-EMPHRIS ENT!r oD •.Qutfa forage t'etY ❑Salinity Barrier: r •
. R ft � �, tut
•' DAquiferTest ..' ' ' '❑StonmwaterD1ainage. • • .
•' ❑Experimental Technology • : ";.��rr t i :2in' �¢::;;,, a •
❑Strbsidesue Control �f
❑Geuthemial(Close d Loop) ❑Tram er. • • - • ' : 2l1 DRILLING LOG.(attach zdathioal ads ifn cersart�l• • : .• .. . . .
FROM TO DE 2UPTION hardness,so1ltedt ate.awn dre etc)
OGeothesmal(fleeting/Cooling Retuln) ' DOther(6:plain.undei#21 ReMarks)
4.Date W... .i..
(3.)Completed: •�/./�0/AnirellIDN . ' . • , ' . /7.„(? rt:. •T S r�. .....-• .. .• I'Ca r1 S A-f r'. .- '
Se.WellLocation: r C /c.
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ft
3tP'1t$-Se�.. ra 4;"C/11-tr(Ou'6'tS . . . f. ft.. ' . .•
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.:Facility/OwnetName - . . , . Facility ID#(if applicable)
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•: ; �ZPt�: 17.`WA-c •
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. . Thysieal Address,City,end Zip.: . . 2i - _ .
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1 b.P. . C1G$S—, oSS3�• . . • .. . . .
County Parcel Iden65eation No.(PIN)
S`b.Latitude and Longitude in degiees/minntes/seconds or decimal degrees: :,'• Z2.:Cei•tidicalion: •. :'•I'
.:' (ifwell field,one:latllong is sufficient) ..: . , ... - • • • ! .,
3 5�)r' /3,a$1e( r 'N: 74 •., -3 ffi e/.,5 6 w 4 r ,_ �� 0.
• Signatmd ofCert• d Well Contactor• i ' • Date -
ti.Ia(are)the well(s):, ermaneat 'er DTetoporary; . ,.•
• • • By Signing this font 1 hereby'eeN{fy that the wel(s)Has(were)caastracted braceonience :
7.Is• '• to an e.••• •:• . ' • l7Yes of ,_: • 1SANC4C 02C.0100 or 154 NCAC 02C.0200 Well Constriction Sf duals a cl,yrat a
g py of this record has beenprovithdto the,well owner. • . . • • • , .
Oiisis arepatr fll out known well construction trr,fonnalion and eaplabr the nalrae offthe . 1''
repair wider#21ronmkssechonoron the bark¢fthisfomm; . ' , • 23,Sitediagramoradditionalwelldetails:.
.You may use the back of this page to provide additional well site details or,well .
8:•Number of wells eonsddeted: •;: .. ::/1.'' :construction details: You may also attach additional ,ages if n
:' For im,Uiptebitxtionorno ..waersupplyweltsONLywiththestonecmurruaro,,yorr.can•:_ • . ' p .
svbitdt ameform : SUB II1TAL INSI'UCITONS
9.Total well•depth belowland surface. • ' //_ c- '' • ' • • •(ft).. 24ar For All Wells: Submit this form within 30 days of completion of well • . '••
Fertr:ubtpie swellilict al1 depths.ifdijarmt(e n 1exm plc 3@200'and2Q100')• . : . .consttuotionto the following: ' . : 1;• I' . ; . : :
: • •: .10.Static water levelbelow,to of Casing:- ' . • Division of Water I nfonnation'Processm .
.rater level isabovecd*Inguie"+' ,. ..: _. -•• . .• ( ' , • . . Servrce�Cm 1617� '
161ZMar1 ti r;'Rale3gL,NC 27ti99-
' . - 11.Boishole df9n *.r. -` ' 4 . •(m j . • ' . . 24k'For Infection Wet,: In addition to sending the'form to the addiess'in 24a '
• • . ,above, also'submit a copy of this•fo ei within 30 days of completion of.well :
12.Welt coirstntction method:•.Rotary• : •• • .•' • • , eaestrucbicin.to the following.- . . .' • .
C.e.anger,iotmy.cable-direct push,•etc.) "
. ' . '' . ••Division of Water Quality,Underground Injection Cannel Program, ..
FOR WATER SUPPLY.WELLS ONLY:. :..1.636.Mail Service Cent er•,RRaleigh,NC'2709-1636 .
BloWin -Ri 24e:For Water Sunnly&Iniection:Wells: In addition to sending the form,to
:13a:yield(gpm) : _ .:1Viefhod of tett: . 9. . .9
. .., • • • 'the•address(es)above,'also submit one.copy In:
this form within 30'days.of
' Chlorine . t�0 '. oz.' ' completion of we],Construction to the:county health department of the county' .
13b.:Disinfection e: Amomt:
where constructed .. '. .:
• Formew-i . • . ' .•North.Carolina Department of Envuonnient and Natural Resources—Division of Water Quality , Revised Jan.2013:" . •