GW1--01664_Well Construction - GW1_20240313

WELL CONSTRUCTION RECORD
For Internal Use ONLY:
'' • This form can be used foi single or multiple wells, ':
1.Well Contractor Information: I
. • Bobby'W. Potts, , 14.WATER-ZONES,•• . ,I I
"PROM TO r DESCRIPTION .
. • :Well Contractor Name : . 'ft.-
t '!(/0 •ft. • I I - • •
•. NCWC 2028 A ': . . J,Y�((� ft
NC Well Contractor Certification Number 15.OUTERCASING(formniti caaed'wells)OR LINER(if Me) '
PROM TO' . .DIAMETER 1 - THICKNESS . MATERIAL •
.- Ferguson's Well.and Pump, LLC . . • - C$ ft ///�fj��•• trr. d GG . z• i
Company Name . ' O.'16.INNER CASING OR Ti G.( mal dosed oup). ' •
• ' • FROM. TO . DIAMETER .THICKNESS• MATERIAL
2.Well Construction Permit#:. . . 0 a of-. O O o a t . - ft . . ft • I .-in,. . . .
List all applicable well construction permits(re.County,State,Variance etc) • _
•.ft ft 1..in.
3.Well Use(sheds well use): 17.SCREEN -
Water Supply:Well: . . PROM TO• DIAMETER SLOT SIZE THICKNESS MATERIAL
• • • ft ft la;
' ❑Agricultural ❑ paUublic P
iDGeothermal(Heating/Cooling Su p1y) Water Supply(single), ft t n
,
❑Industrial/Commercial,- . . . . I:Residential Water Supply(shared) . 1&GROUT • - '
❑Irrigation PROM TO MATERIAL. . EMPLACEMENTMEIHOD&!'AMOUNTe ' •
Non-Water Supply.Well: 0 ; ft 20 ft Concrete' Grevity•4EI• p. F,.,'�£ V.1,--
• '❑Monitoring • . ❑Recovery • ft ft M�� ; '707�
• Injection Well: ft• ft • , . •
❑Aquifer Recharge: ' CGroundwatcr Remediation • 19.SAND/GRAVEL PACK Of aniuiicable) 1..-�?s:? riz4.111`?"".--
PROM..
TO MATERIAL s '$CC31��lE32IODi
❑Aquifer.Storage.and Recovery • ❑cal;nity.Barrier .
ft . . . . - .
• ❑Aquifer Test . ❑Stormwater Drainage, . '• , .
❑F.xperimenW Technology • OSubsidence Control • Z0,DRILLINGLOG.(attadr additlnnal sheets ifaeemsary) : /• •
II'
•
•
❑Geothermal(Closed Loup) DTracer _ •.• FROM.• TO • DESCRIPTION(color,hardness,soli rock type,gram size,etc).
❑Geothermal(Heatia Conlin Return) • DOtheru
B/ 8 Al (explain under#i21 Remadcs) ( is 'ft' J��
4.Date Well(a)Completed: 3 Well ION . • ' (f5.f° �( � ft `S`G/hj G`S�Cl�f
: •ft' ft
•5a Well Location::. • • tY R �S ft' • • �r .
7hlil l�4-A'C R ft.
'
• Facility/OwaerName . Facility ID#(if applicable) ft ft . . .
t ttQ. PF) rt .L 4n e: e �- tJ L3o� •
•ft . ft ' •
c,.
" ' Physical Address,'City;and Zip. 2L REMARKS . •
I-20l,tt��fyN,6� e . �c.l�y -r 31 o
Cosh' Parcel Identification No.(MN) . • �"
•
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: . i - :
(if well field,one lat/long is sufficient) • • 22.Ce 60 •
.4.41:• . .• ‘
3?2e34`iGSlx N 4A9 ' /3>a2yt'' • W
Signature of ell,Contactor ;,' -Dat
• • :6.Is(are)the well(s)::C�IPermaneat• or ❑Temporary. w• . . n
B3'signing tills form,I•hereby certify that the weA(s)war(were)aonsbuctedin accordance
with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Stairdmds and that a
7.Is this a repair to an existing.well:• ❑Yes or Ci'No • • . • •
'copy ofthis record has beenprorkkdtotheiweltowner. -- .
. Ifthis is a repair,Jill out blown well construction information antiesplahr the nature of the
' repair ruder#21 remarks section or on the bark of thisfOnn. , . ' • 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 of wells constructed: • ' • i • construction details.:You may also attach additional pages if necessary. • • '
For multiple byectiai or non-water supply wells ONLY with the same consbadion,you.cern . -
subirdt one form. SUBbII1TA.L INSTUCTIONS 1 •
9:Total well depth below land surface: SDS (ft) 24a. For All Wells: Submit this form Within 30 days of completion'of well . - .
For multiple wells list all depth.s,ftherort(example-3Q200'and2Qa 100') construction to Ihe following: • I
' 10.•Static water level below top of casing: ' t I/ , '' (ft) . Division of Water Quality,Information Processing Unit, • . '
If water level is above casing;use"+"' - ' 1617 Mail Service Center;Raleigh;NC 27699.1617 ' '
•
11.Borehole diameter". • _ • (42 (in-) 24b.For Iniection Wells: In addition-addition-to sending the form to the address in 24a
• • • above, also:submit a.copy of this form-within 30 days..of•completion•of well
- 1L Well construction Method: :ROtary ' . ' . un •cstt'uction to the following: I '
- (i.e.auger,rotary,cable,direct push,etc.) 1'
' Division n of Water Qualify;Und greimd Injection m Control Pangra , '
• FOR WATER SUPPLY WELLS ONLY: • ' • 1636 Mail Service Center;Raleigh,NC 27699-1636
Blowirl RI 24c.For Water Supply&Injection Wells: In addition to:sea the form to
• 13a.Yield(Spin) Method of test+ .U- U
. . . . • . . . the.address(es),above, also.submit one copy of this.form within•30 days of •
•• 136 Dismfectiontype: Chlorine• : Amount: tr� oz; completion ofWell construction to•the county health department of,the county-
. . where constructed I
{
Form C W-1•• • • North.Carelina Department of Enviroament'and Natural Resources-Division of Water.Qiality 1 . ' • . ' . .'Revised Jan.2013 •
• 1 •