GW1--01659_Well Construction - GW1_20240313

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.WELL CONSTRUCTION•RECORD • •ForInftrnal.UsaONLY: • k • .
::This form male used furlong(:or multiple wells
- 1.Well Contractor Infortuatiun: :
Bobb W. Potts . • • • . : 14.WATER zoo _;' . . i ..
7 . FROM. .PTO •.' ,• DESCRIPTION . .
' , •.. :Well Contractor.Nano .: : ...•. . : , : • ft. Oft
NCWC 2028-A . rt 1(0 : . . 1 I:: - - • • -
NCWd tia lConetorCcrtifica6onNember • • 15.OUTER G(farIDnlEl iadwdIs)ORLINER6fangaHe)
. FROM •. TO DIAMETER THICKNESS •MATERIAL. .
. • Ferguson's Welland Pump, LLC ' 0 ft': c t .f . (Q.-a,Slio. ?./6,J '. Pb cS,j)/LZ/ •
Company Mime• • • • - . ••• • • • • 16.1NNER CASING ORTUSING(te Odirsmaldatied Ioon)'• : •'' .
'` /fin /� ` Q ^� FROM• TO- DIAML�'1'F.R• • • "THICKNESS' MATERIAL .
•.• 2.Well Coastr sdlcn Permit#: . C71t>dt 3 O V l O O' .ft ft in.• .
'List all appdcabk wen ca►rintetfon panne(ia.Cowrdy,State,Vegiance etc) •.
• to ft . in.
. :3.Well Use(check well use): . : :
17.SQtEEN. .
Water Soppy Well: .•: . . : •: . FROM:• TO DIAMETER SLOT NEE •TIIICIflJEES MATERIAL
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❑Agricultural• ' . -' ' .❑IvcipaUPublic ..ft • ft • , im.
❑Geothermal(Hcating/Cooling Supply) •ORes.slential Water Supply(ogle). • •. ' it • ft . II.' . . .
. . ❑In dustrialVCommercial 1 . . ❑ esidential Water Supply.(shared) .: 1a GROUT .
FROM. TO ". . MATERIAL . EMPLACEMENT METHOD a AMOUNT .
Non--water well: . 0 ft, 20 - ft Concrete .Gravity: low r. "' ; f;
Supply . . •
OMonitoriug . ❑Recov • ft tt �•' 4.....7 u 9,_f�,'
cry
. :Injection Well: ft. . ft :MAR 1 2024
❑Aquifer Recharge..- • , ❑GroundwaterRemediadon . 19.SAND/GRAVEL PACK fd e) . . . . . .
�Agtllfer'Stoiu andRecov FROM' TO ' MATERIAL' Du:t't.`..f
i cry'. . ❑Salmlty 4 'er . . . ft . . awcu,3,0
❑Aquifer Test. . ❑Stomtwater Drainage I'
. • :❑Experimental Technology • ' ❑Subsidence Control i •t,
. . ❑Geuthem. . (Closed . ❑Tracer . . • DRILLING LOG(stoaeLDaddidi sheets if ) •' • • . . • • '• .
. a�
( . p) . .• . . . . : . . ,.: . . ONcralar,hardness,sdurodr type,vela du,rte.)
. . -OGeotheirmal(Heating/Cooling Return) ••❑Other(explain under 421 Remarks). . - • .
. . 1, :frt.' �o, �.it . �'�ll�••VA_`
' 4.Date Well(s)Completed: . Well ID# t'D D it.. , S. . ��s �
• • • • • • • • • 7.. 5?5'. ft' )1,4et*o tic . . .•
sa.wdi Loc Lion: • • .
. S ft t
��!. OS. �a�a t-✓r 7t.e
FacilitigiveerN • _ • • FacilityII)ii•(ifapplicable)., ' • • ' • 'I ' •, • . .
fL. ft
T prrtie' 'ZI 14 ,gill( •0886s" • . : ft , : ft • ' : • :
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. Physical Address,City,and,Zip ' • 2L REMARES•. • I • • ' •
• unCC Vie'•. . 41(oOt 3 5.apti• . . l
County Parcel Identification No.(PIN) . i ' -
• Sb.Latitude and Longitude in degrees/minntesMeconds or decimal degrees: .
(if wall geld,one latfong is,suffioiaat) 22 Certitieation:. .,
•:31.93•1/t3, 4- V 2°a?33.,$-S3to.. . w. . .:.. ` 4 . rp' : da%3 .
Signature of C eel Well Contra:
6.Is(are)the well(s): c •ermaneat. or ❑Trmpornry:. • rids '
.•. . . • .
'$y S1g/WIg fornT I hemby cert#y.trial 1/le well(S)was(were)carcrrrxted to accordmrca . ..
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• with ISA NCAC 02C.0100 or lSeINGIC 02C.02001EeU:Coi>sYruetlaRStmsdmrlt and that
• • • 7.Is this a repair to an existing well• ❑Yes • or •�1No• " . . .with
of this cmdhds beenprovlduito the ww,owner.. . . .
'Orb is a repair,Jill outloime,well constniciwn bfermalloa andeaplain the nahne the o - - . : . ' '. .
repair wider#21 sanaikkrarction or on the back of thtsfann. . f • 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 dwells Constructed: • construction details._You may also attach additional pages if necessary. • •
: Formoldpk allecdaiorrwn-waiersypply wells ONLY.with the same coast rrlion,you'can'•
submit a efo>m S1UB11�'1TAL INSTUCITONS I
9w et wues • SOS • • fTotadphbrolanda t) 24a. it+or All Well®: Submit this form:within 30 days of completion of well .
For mddople tod47.ftl all depths.ifelliferimt(es�mnple:.3@200'and2®l00') . . . . • . " ., coast action to the following: ` j. • . . : • .
10..Static water level below topof casiagi • . AID •• '`- '(ft.) Division of Water Quality;Information Processing Unit, ' . , .
' rioter keel Li above mil*use"+" •/ . '1617 Mail Service Center,Raleigh,NC 27699-1617 - .
. 11..Botehole diameter. ` • lQ• (in.) • ' 24b.k'or Injection Weld In addition to sending the form tithe address in 24a , •
.• . . . . . ROta • • • . . above,.also:submit a copy.of this:fours within.30 days.of completion.of well • : . .
: . . 12..Well eensteaction method: . ry :. . • ' convtruction to the following: ..: , "
(i.e.;auger,notary,:aab!;direct push.otc.) .. . . . .•
. • Division of water,Qualiiy,Underground Injection Condvl Pmgeam,
. ' FOR WATER SUPPLY WELLS ONLY:.•. ' • ' . • • • • •. . • • - ' .1636 Mail Service Center;Raleigh,NC 27699-1636. .
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13a:Yield'(gpm) . :g • • • •.Method of test:_-Blowing-Rig . . . 24c.For Water Sun' nit&Inaction.Wells: In addition to sending the form to .
l . the.addresses) above'also:submit one I copy of this form within.30 days of
13ti.Disinfection type: Chlorine.: ::.Amount:: .qA• ' •. .Oz..•. completion of wel construction to the county health department of the county :
..where constructed. I .
' . Form GW-1 . • North Ca,olinaDepartment ofEnvironment and Namurl Resour es—Division of Wafer Quality 1 'Revised Jan.2013 : •