GW1--01660_Well Construction - GW1_20240313

• WELL.CONSTRUCTION RECORD ' . . : For Internal Use ONLY
. :This form can be used farsingle or mattiple wells . • , • .
.1.Well Conttsdor Information: '
• Bobby W. Potts . PR4OA .7OTONEst , D ON • .
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f.
•Weill Contractor Norm - • . . . . 4 d: . I .
NCWC 2028-A . . , . :it' 3 go ft. I i.. . ' .
NC Welt Contiactor Certification Number' 1S.OUTERCASING(for mnlS.c Fedwells)ORLINER(iif cable)' - • ,
FROM TO. DIAMETER TRIMNESS MATERIAL -
Ferguson'sWell end Pump, LLC . f'
Company Name .. . 16 CAS NG ORTU8 NG ref i 1tamal dmed40UD)
FROM. TO. . DIAMI R THICHIVFSS• MATERIAL
'2.wdl Construction Perndt#: • • 7 6 Z 3•- •a•0 203. R. . , . ft
List all ppdeable well construction permits(L'e..Cmort},State,Yatiane4 etc.) .. •
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. :3.Well Use(Cheek well use): . . ' •. . . . . . , . 17.SCREEN
Water Supply Went PROM TO. DIAMETER' SLOT SIZE .'ITOCENESS MATERIAL
OAgncultural. • .•. '.I• • . . pal/public • • ,ft ft ior•' . • .
OGeotheimal(HeatingiCooling Supply) • esidential Water Supply(single!). - • . ft • . fe' !IL1' • .
1&GROUT -'' •❑IndasOtia]ICommercial ❑Residential WaterSupp. .- •red) . .FROM . • TO . . MATERIAL•• •EMPLACE •ENTMEMOD&AMOUNT.•. •
❑hns;ahon • • 0:•• 20 Concrete,.• • `.Gravity-Flog V L r
•, Non Water Supply Wear.• . ,.
ft . i+..,!fir,'.
❑Monitoring . • • . ❑Recovery . f_ -MAK• c.2O2
.Injection Well: - .ft. - ft.
�i f:'-''" .' t
.❑Aquifer Recharge. ❑GrouadtiVater Remediadon" 19.SAND/G1tAVSL PAC7►(if aalolfcaHe) • ;��aC;:� l�R�'
.❑A SL aid Reco ' . • . FROM. TO . ;MATERIAL . . . .F�LAcell • rsl W11IOD '
q` a o . . . . . ❑Salinity Barrier , . • ft ft .'i
❑Aquifer.Test . ❑Stormwater Drainage . . .
• . . :❑Experimental Teclmoiogy • • OSubsidence Control . . ft • . I' . . . .i - o. • -
. OGeuthemial(closed Loup) •. ' ' .. 1OTraiar • ' FFRRO DRILLING
.. DESORPTION(LOGfattath ar, sdumdctype erahlma )
❑Geothermal(Heating/Cooling Return) .•DOther(explain under#21 Remadcs) ft. 6. ..5. It. : i,C
y
4:Data Well(s)Completed: Weu m# • • .6 g.ft To ft• i. S cr 4� l#tc
54ft fit ft.
: : / CieSa.WeII Location: .. n Y a�
"fAF/: a �. : . • .ems t . • • l(, ,t,�
- FacilitylOwaerName Facility ID#(if applicable). • li
ft ft'
• -98-: -?Vn '/ 0 .• _6..P// ��9y• • ft.. • . ft . : .
• , Physical Address:'City,and Zip: 21:REl1lARKB'•
7:3r,,nt'isnthr • .. . q76 36q(e/W .
County Panel IdentificaeonNo.(PIN) .
.Sb.Latitude and Longitude in degreeslmianteskeionds or decimal degrees:' . • 22.Cerrtifcation:.• • • • • •
(ifwell field,one latllong is suii.fficient) : ' .
• . -'i c°•yz•''Y3, . : N:. a'. A . 3.bes'.5 �. w- - ,, f� ,_ . . / ,e�. a. . '
� . . •
. . si of Cerlffied well atlas r . •,.
• : 6.Is(are)the well(s)::C3erm inset..•or. OTemporimy, - • • : •
• • :By sigtmrg thts farm 7.tieteliy ctrq'Jy,Brio the weA(sj iras'(rren)'co►estrrrctid iir aceoidmtix•� : ' '
with 154 NCAC 02C.0100 or 15ANCAC 02C.0200 Well Cowatietlon&mrdmrls and that a •
. 7.Is this a repair to.an'existing.Welk.- ❑Yea.or •'l o. . .. .'. copy'ddsrecondhasbeet:previa:dielhe'.wellcrane. .• • ' . • .. . , .
. •Iflids isa repair;fill etd brown well eoncbudiots bWarination and cxplabr,the natroe gfthe -: ' •
repair wider#21rentarAsssction or on thebadcofdrisfans ' . • 23.Sitediagramoradditlonalwelldetails: ' •• ' .'
You may use the back of this page:toi provide additional well site details or well : .
S.Number of wells constructed.. ' . f '. .. • • '. • • . .construction details. You may also attach additional pages'if necessary. ''
' Fcriiarldple irt/ectiaRorno►:-watersvpplywells 01VLYwth the same ovisttrection,yoee eat • • . '
sabttrt onefoma SI]BMITTAL INSTUCITONS .
9:I.:tit:Si well depth below land surface: 4/al5 • (ft'.)• 24a. For"AR Walls: Submit this forth within 30 days of completion of well'
:Formmbiple iwei/slist al depths ifdrffetrnt fora nple:B®200'and2(a)100) . • ' • ' construction to.the following: - :
10;Static water level beloa-top of casing: :• YO' ' - g•. '(ft') . • - Division of Water Quality,Information Processing Unit, , :
• .Mitt&level is above easing live"+" - . •1617 Mall Service Center;Raleigh,NC 27699-1617 • . . .
11:Borehole diameter: -. (in.) ' 24b.For linieetinn Waite In addition to sending the form to the address in 24a .
ROfa, : above, also;submit a copy of this:fe ,within,30 days,of,completioo of well .
. ' 12.Well construction method: • • • construction to the following: • .. • • _ :
(Lc.auger,rotary,table;dater push,arc.)
• Divlsioa of Wmter'l2nality,'underground Injectien Control Program, '
FOR WATER SUPPLY WELLS ONLY • 1636 Marl Service Ceat'r,'Raleigli,NC 27699-1636 . • .
13a:Yuld(•gpn<) J Method of test: Blowing-Rig 24c.For Water glumly&Iaieation Welk:•In addition to'sending the form to - .
. . the.address(es).above, also submit one copy of this form within 30'days of
• • • :'' .i.. •.on Chlorine Amount: completion of well construction to the'county.health.department.of the county . . : •
type: OZ.. . where conatrhated. f
:Form 6W 1: North'CarolinaDepertnient of Envimument and Natural Resources-Druision of Water Quality • • Revised Jan.2013