GW1--01655_Well Construction - GW1_20240313

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.WELL:CONSTRUCTION RECORD'- r • • For Inratnal.U• ONLY: . : ' , ' • .
Tti:s form can be used forsingle or tuulQple wells . :
1.Volt Contractor lnformatsun: ' . • • • • • •
•'•Bobby:W. Potts • • • • FROM • H 1d. I DESCRIPTION . • : • • . . • .• • .
Well Coat . o • • • • • • � I. ) •,. .. m
.• . ..' • NCWC 2028-A • •
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:NC Well Contractor CertificaiionNumber
15.flUTERCASIIVG(formnl4c�+edirells)OBLIl�IBdtfd�He)
FROM TO, DIAi1�lP1t I TffiCSNE4S MATF1iIAL'.
Ferguson's •Well.•and Pu• mp, LL• C • • . • . '.6 . - i,A 5 :h:.. 216i11 o,cs 2,
Coin Name 16.INNERi:E�GORTQBNG(spcothe:malelased4OoD)
. -• -:• • PROM• TO, i DIAI/E1231 . . 'TEUCKNFSB• MATERIAL .'. .
•' •2.Well.Construction Permit#:'• ..DOa L I.;.- L)0 Oft).Pi ' .• .it.. .• ft. . ' I'. n-
. •List all applicable veil canstrucdat perndils(Le..County,5lote,Yarimrcc etc.) . •••. t- i ' • •
' • 3 Well Use(check welluse): . ° : : • • .
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Water.Supply Welle FROM`• To. DLfMFTER swrstzn TIIIC NE4S MATERIAL
OGeothercial,(Heating/Cooliag S�tgply) •dential Water Supply(ogle), ' •. • ft ' • •••it . 6t:.; • • • • •
•OladustciaUCommercial OResidential Water S 1. • 18.GROUT •: -
uPR Y • M TO MATERIAL' ""E[6pL;10ENIl�A7TME[HOD'A'AMOUNT:
Nonon-Water SdpplyW�e 0: 'ft-, 20 •.• ft Concrete Graitn-Frgw—k;?--;,y •'-f.
l7Monttonag ORecovery, fc ft • ,. •. 1.,;.,1
• Igicetion Well: • . • • .ft. • ft MAR 1 2024 .
'' ;DA. •gnt • • . .
. ferRecbarge,' `� QGrouadwaterRemediaaon '" 19.SAND)tiRAVSLPACKfdiDpifafile) .�:
OAquifer Storage and Recovery• • .. DCat;nity.Bamer PROM•` TO • :MATERIAL. ,p va•MIraonm I s�;I' .
' 6 Di�JCu`�Ji .
• •OAquifer,Test . • . .DStomiwater Drainage .
• •O ental Technolo' - DSubsidence Control . . • ' ' ' • ' t: : •
ft ft
®' 20cDRILLINGLOG.(attadiadditimalaheoestfnev�atsi)
l7Geothasmal(Closed Loup) . • • OTraurr PROM.• TO D ON(calor,Hardness.soarovt Due.crate du,de) • ,
.', •CGeothermal(lieatiag/Cooling Return) OOthec(explain under#21 Remarks). : ' ,t?•' 60 . ..ft • i`.;• • :
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• 4:'Date WeII(s)completed; S y_•'Well ID#• • • • (� fa' '/S t` lt'71t /7l
• • 7S'tt. • . t :I1 ' .c.ptt.e'r/c• •
s .Wa1 •Location • . . .i
/ 'ftvs. ft • , j, ,
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Faclity/0wnerName ' FacilityID#(ifapplicable) , ' . .
32'-J:...L-1 Pvnt+r•'''' Otst - La•n� U.)o rlr.ub((e'ofr5 r :ft ' 'ft .
. Physical Address;City,and Zip: • . t:'REMABI S
1l r,rcv' i(O e. . . q 7u.Is gss6. ago.. . . . . '
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County Parcel ldenufieanon No.(PIN) i;
. . .... "b.Latitude and Longitude m degr eeelminutes%econds•or decimal degrees:• - •2 Cerication '
(if wall field,one:letilong is sufficient) , . . • . . - • -, •
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.• • *°UO 'YA.77ti . N'601 3A.:33.d°15'r34 W.
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f eel WelfCoatra�tor
• 6.Is(ate)thewell(s):: ermaueat ur• OTraaporary... ,• • . . . . .
• • •` $�Sigrdin$tlTlS fOTnl,1 hereby..w��.t��ll7e liell�S)WfB(were). �Car�101Ce '. .•,:.
with 15ANCAC 02C.0400 or 15ANCACi02C.020.0 iWe!Constractieniswzdeo is arrdthata •
•. "7,Is this a repair to.an'esisting•welL• • OYes or ClT1Vo •' • • • . • `copy of this record has beenprovtakdto ~yellowirer • . . ' .
. •7f this i;a repair,fill out!mown well eonsbuction of nnration caderplain the nature ofthe ''. '
npair wider#21nonorksswchonoron the back ofthisfonn • ' 23.SitediagramoradditionalWelldetails:' -
r ba of to i
•&'Number ofwells constructed • ' / ' • • • 'construction details. You mayo attach additional pages if necessary • '
: . . .• : : .. details or well
FornaJHN,bpeotiiceior non-Water sapply wells ONLY with the same c te:sMution,you emi' Z T I, ., • •• • • • •• ••• ••• •• •••
subnn afefonn.
:. 'SIJ91VI1TAL•INSUCTIONS .
9.Total well depth below lend surface: • (ft;) •24a. For All-Wells Submit this form within 30 days of completion of' well'
Fornndbiple rellslist all depths fdferodt(eran3Pk=J@25S 00•arrd2@100') construction to:the fo11owing
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10.Static water level below top'of rorwrg,0' (ft) Division of Water Qualitlyyl ,Information Processing Unit,
' "Water level is above casi idle'+" Cate,Raleigh,NC 27699-1617 .
. . . •.' .- 1617117aQ Servicer .
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• . •11:Borehole diameter •d v (in.)' . • 24L.For Inieetiou Welt:: In addition to sending the form to the address is 24a . ,.
',form Rot • above,.also:submit a copy.of this:f within.30 days of completion of well. .....
'12.Well`construction Method a-.ry :- .••• 'construaion to the following
uger,rotary,:cable;d rectpush,etc.).
Division of WaterQnatity;Underground InjocHoa Control Program,•• FOR WATER SUPPLY WELLS ONLY: • . ' • ' • • .:' 1636 Kati Service Center Raleigh,NC 27699-1636. .
• .' • :. ' Blowing-Rig . 24i.For Water&touly&•Inie¢tiun(Wells:'In addition to sending the form to
13a.•Yield(spin) ' . . Method'of terms • - the-addiess(es)above,`also:submit one copy of this form within 30 days of:.
` •Chlorine • •• - . : completion•of
•• 136.Disfmfsctioa type: '. .Amount:� �0 •,OZ. well constructwn to the county health department of the county .
.where constructed. I .: ..
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Form CW--1- . ' • ' NoftkCamhnaDcpattment of Enyironmentand Natural Resorttens—Division of Water('aality . .•Revised Jan.2013