GW1--04134_Well Construction - GW1_20240717

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells •
1.Well Contractor Information:
14.WATER•ZONES_
Bobby W. Potts FROM TO .- r DESCRIPTION
Well Contractor Name ft / ft
NCWC 2028-A ft ,q ft
NC Well Contractor Certification Number 1S.OUTER CASING(for multi-cased wells)OR LINER(if apgia61e)
PROM TO DIAMETER THICKNESS MATERIAL
Ferguson's Well and Pump, LLC C, tw 6, ,! , ;it") St4c/
Company Name 16.INNER CASING OR TUBING(geothermal claseddoop)
`� ft ft FROM TO DIAMETER THICKNESS MATERIAL
�2.Well Construction Permit#: L/ ._13 6
List all applicable well construction permits(i.e.County,State,Variance- etc.) ft ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE TRIMNESS MATERIAL
[Agricultural ❑Municipal/Public ft ft in
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft IIIL
❑IndustriallCommercial ❑Residential Water Supply(shared) 18.GROUT —_ -
PROM TO MATERIAL ' EAIPLACIII ENTMEIHOD&AMOUNT
❑Irrigation ___INon Water Supply Well: • - it 20 ft Conere?:e—Gravity-Flow
•
❑Monitoring ❑Recovery it _ it _^
Injection Well: ft. ft.
—
0 Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK tif macs hde)
FROM TO MATERI.L EMPLACEMENT METHOD
.3______.❑Aquifer Storage and Recovery ❑Salinity Barrier ft ti —
El Aquifer Test ❑Stomiwater Drainage ft. ft
❑Experimental Technology 0 Subsidence Control t
20.DRILLING LOG(attach additional sheets if necessary)
❑Geuthetmal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,solvrod&type,erne due,etc)
°Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) . it 3 C ft C/a,`
Well(a)Completed: �J/4/`/Well 1D# 3�+ ��' ft
4.Date We ��, —
Sa well Location: ,Ye ft y it� —/1 C '��J C/e
oiii(7 ei'Ai9/Narca� P R yd. ft. 3�- ft �+ avl�c cF tty/Oweter Name Facility ID#(if applicable)
R ft
-1 Ci9Q4' fUu f?oX)-L-/ tg/astir �8'7548 ft ' ft
Physical Andress City,and Zip 2L REMARKS In,`
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field one lat/long is sufficient) 22.Certification:
.S '. 5'jai%; `/35' N O`/`/ 3l/e)q '`3 9 W ,�t: (: '" //7 ; -' t/
Sigitantre of Ce Sect Well Contractor Da
6.Is(are)the well(s): 0. eraranent or ❑Temporary By signing this form,I hereby certifi,thel the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or 15.4 NCAC.'02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or Sago copy of this record has been provided to Me well owner.
If this is a repair,fill old known well construction information and explain the nature of the
repair wider#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
,e You may use the back of this page to provide additional well site details or well
8.Number of wets constructed: / construction details. You may also attach additional pages if necessary.
For multiple tiy'ection or non-water supply wells ONLY with the saute construction,you can
submit one form SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: C.' (B,) 24a. For All Wells: Submit this form within 30 days of completion of well
For muhipk wells list all depths(Idifferent(example-3@200'and 2Q100') construction to the following:
•
10.Static water level below top of casing: /i r' ; (g,) Division of Water Quality,Information Processing Unit,
11.water level is above casing,use"+" r 1617 Mail Service Crater,Raleigh,NC 27699-1617
11.Borehole diameter. i 6 (in.) 24b_For Iniection Wear: In addition to sending the form to the address in 24a
Rota above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ry construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Matz Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) w ., Method of teat: Blowing-Rig 24c.For Water Simply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b Disinfection type: Chlorine Amount - 5'!? oZ completion of well construction to the county health department of the county
C where constructed
Form OW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Tan.2013