GW1--01663_Well Construction - GW1_20240313

.WELL CONSTRUCTION RECORD" . - .
For Inleraal Ilse ONLY: •
•I.Wei canbe used foe or multiple wells •: . . "
This formI � . . •
'ContiricturInfonnation: •"
• ' .: Bobby W. Potts . • - ,14 HATER ZONES..:r •'DFBCRIPTION .
. :,::WallContacoor,Name" .:: . -: - 1 . . . "R: 270.: .. .1. {. . ' . :
NCWC 2028-A : ft gyeit:
. .:NCWellContiaetorCertifieaiioaxnmber " - • • •15.OUTEQ�ASING(farninl8smed welts)ORIINEROfauual1e) .
. ' FROM . -•` TO DIAMETER! THICKNESS • .MATERIAL'. ' .
.- Ferguson's Well.and"Pump;, LLC , . • 0 fc.: : " • (r `.hi. zte v j•. f&cSp,9Z/
Company Name _ • 1(i.INNER CASING ORTUIi'[NG"(aeul>ittmal dmed4oup)
: 2.Weil Constsoeblon Pertmit#-. ' a oa 3 :O G 6 a'. .FROM" ft TO, ". . R 'DIAMETER '.. : . . . . ' .• • " THICKNESS" MATERIAL
list all applieable well caisrneolon per»rils-(le.Couniy,SYate.Yan'ancc eta) • ' . _ ,
n •. f� hr.•• •
3.Well Use(cheek well use): . :' : '
: . . Water Supply.Weld . . . ' . . . . . . ' . . : , . ' FROM.• TO• DIAMETER I SLOT SIZE •TRIMNESS• MATERIAL ,
DAgi��: . •• If- • ' .: • d lic . . ,ft _ ft n`; • „ .
QGeothermai_(Heating/Cgoling Supply) Water Supply(ogle)" . tt. • ft . 6r:; .: • • • • • . .
OIudustkiaYCommerrial, , • " : . . . OResidential Water Supply(shared) 18.GROIIT . " : . . - . . '
t7laigatian a FROM TO MATERIAL y inWIACEMENrMETHOD AMOUNT
•
Non-water Supply.Wella 0: ft'. 20 . ft Concrete ' rGraviity'rEloy4, •:
ft.: ft. i•.kL.L .11.147....i
' l7Monitoruig. . . QRecovery ', �
. Injecttoon Well• ' . I'' ° A n OAguferRechiuge - DGroundwaterRe•mediation 19.SAND/GRAVEL PACK tifamdieable) • . •
FROM•. TO .MATERIAL EMPLACFNESt•METHOD ' •
OAguifer Stained and Recovery. . . ❑Salinity Barrier.: ft.- ? ii fv.,1*w;c.; e.r; .t.o. p t��;}; . . •
OAquifer.Test" , OStomrwaterDtainage .: k i L �. �.-1�� '`" _ , ,
' • :'OExperimeatal Technology ' . - DSubsidcnce.Control' - • ' ." • " - ' " ' p:
. 2O.DRn?GLOG.(atmeb addHmal ahatstrmzsearyl
• 'CGeuthtmmal(Clused Loop) DTracer - ' FROM . TO • .DFSC !TON(color,hardness,tolUrock(see,grata due,etc.) •' • ,
"OGeotheimal(Heatitig/CoolingRahn). ""DOther(=plaia under#21 Remarks). . 0,fc ..3a 1 ..ft • . . r.(rA .: _. • • ,. ' •
.4.Date Wells)Completed: I /Y/23 WeuID# . ' . ; . • R 5, 5
" 5a.well Location. : •. • . • - t •
• . .:: R f
• .Dp•t i / Pa rrflYl. : . . . ft . f.'
. Facility/OamciName , " , " ' • ,- . . 'Facility mD#(ifapplicablej ft ft I'
/Ua'vrbrl: •(ZEAge: " iP. ": 6.4el i•v o,9730: :fi. - . .ft. "
- � Z1.REI1fARI�" • •
Physical Address,City:and Zip •County • Panel IdeadficationNo.(PIN)
• 5b.Latitude and Longitude in degrees/minutes/eeconds or decimal degrees: I' .
. (ifdrell fiold,one letlloag is•srrffieidat)
2L Certit?ca'
•. 3S©3p ylt g?25 N 271 S72f12 �° W e, •G�%• • •
� Srg�tom well Contractor . i - .
6:.Ia(are)thewdl(s)::l armaneat'-'or :OTrmporary. . r '
. � � BY sigrrirrg�1�I hweby eerQf�!.that lire,wv:A(s)was(wwe)�cansEracted in'accordmree•"
" with 1SANCAC 02C'.0100 or ISA NCAC 02C.0200 Well ConstructlaaSlarrdards anddmt a,
'' • - 7.Isthisarepairto•anexisting-well••. OEM •or "'flNo• • • ' . " • copy ofdila record hasbeenpmvlakdtothewe*Iowner' " . . ' . .• ' . • • • . .
.•.fjlhts is a mp b fill out rn well consirudion b ihetmdion andesplabr the nature of the •'• "• I. . '" . • . .. . ' , . ' •
• rerpelrcorder#21 reouolsseciiorr or ea:the back of thisfo m. • • 23.Site'diagram or additional well details: .
' : - : Yon may use the back of this page:to provide'additional well site details or well :: . .'.
' &Number of welts cunstiuetedr : • '/ ' . • ' ' construction details.You may also attach ch additional pages if necessary."
Fornmlrlpleilleetiarornorr-water*supply wellsO11LYwhbdre some carabuction,yourcan : • ''• •••.
sabir>it a+refanra S1JBl,D1TAL INSTUCTIONS
9:Totalwel depth below land surfacrw Yd_S • . g(i) " 24a. For All Wells: Submit this•form within 30 days of completion of well ,
:Fora Diple wells All andepdis.tfdffaeiit.(exanple-3@200'and 2(d 100) . . construction to the following: yy
' 10,Static water"level below"top
'of casing:. • 7 '' (it) " Division of Water Quality,:Information Pr�oces�g Unit, ;
lfwiaterlevellIabo►recatbrg;sire"+" .. " • • ' 1617 Mail Service Cutter,Raleigh;NC27699-1617
I1.Borehole diameter' (m) 24b.For Inje rtion Wellic In �" to sending the form to'the address in 24a
• " alloy;.also:submit a.copy.of.this fomn within 30 days.of.completion,of well ' .
: : 12.Well construction method: •Rota./Y" • • ' . • boast<uction to the folioaing; ' ! , .: '
. • (i.e.auger;rotary,:eable,direct push,ate.). : • : I "d -. • • •. "
•• ' . . . . Divleion of Water Quality, un Injecting Control Program,
. • FOR WATER SUPPLY WELLS ONLY: • ' ' •. ' •. ' •. " . ' . ' ' . ' 1.636 Mail Service Center;Raleigh,NC 27699-1636. . • , ' •
13a Mudd' nz •• • Hell•ion of•testi"Blowing-Rig • • 24c.For Water Samlee&Infection Wells:'In addition to.seuding the form to -
cep . :f`Q : '
.. ".. . . . the.address(es)above, also:submit one:{copy of this,form within.30 days of
•Chlorine : •L/,�; O - completion of•wen construction"'to•th'e county•health department,of the county. .
13b.muto,lfection type: . "Amount:" " where constructed.. ` 1 .
. • •:FormCW-1.: : , .:. .' NorthcarolinaDopertm Environment aid Natural Resource's—Division of Water.Qurdtyi . •. Revised Jan.2013:.• •