GW1--04153_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:
BobbyW. Potts IAWATER-ZONES
FROM TO • r DESCRIPTION
Well Contractor Name ft. ! ft
•
NCWC 2028-A ft a?Oft
NC Well Contractor Certification Number • 15.OUTER CASING(for multi—anal wills)OR LINER Of applicable)
PROM _TO DIAMETER THICKNESS MATERIAL
Ferguson's Well and Pump, LLC f* Ye) ft' 4�,?S in. f gS S Sc c/
Company Name 16. CASING OR T, 'iG Wethermal dosed-loop)
^� FROM TO DIAMETER THICKNESS MATERIAL
c 2.wen construction Permit#: (Y .-6 - 6 Q L S O ft. ft in. —
List all applicable well construction permits(i.e.County,State,'Varim+ce,ere) —
it It in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER_SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Muni public `t ft. in.
❑Geothermal(Heating/Cooling Supply) es�R idential Water Supply(single) ft ft in.
❑lndustiriaUCommercial ❑Residential Water Supply(shared) 18.GROUT -
FROM TO MATERIAL ' EMPLACEMENT MEIHOD&AMOUNT
❑Irrigation --
Well:
0 it 20 Concrete—�Gravity-Flow
Non-Water Supply
❑Monitoring ❑Recovery _ ft. ft —_
7
Injection Well: f- ft
❑Aquifer Recharge 0 Groundwater Remediation 19.SAND/GRAVEL PACK(if agptlaadc)
FROM TO MATERIAL EMPLACEMENT METHOD
r-�
❑Aquifer Storage and Recovery 0 Salinity Barrier ft
❑Aquifer Test ❑Stonnwater Drainage
ft. ft
❑Experimental Technology ❑Subsidence Control ., r
20.DRILLING LOG(attach additional sheets if nay)
❑Geuthctmal(Closed Loup) ❑Tracer PROM TO DESCRIPTION rotor,hardness,solUrods type,train she,de.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) V 2.0
l/ft .ft p _ay
4.Date Wens)Completed: 6�2/2 y well ID# 20 it 30 ft. -45111-4-4- itgaZr 3
5a Well Location: /) ft 92 rt
/C� ft 3�S ft 242 jl c
A 0,..1r.e,D Krvi-i it riuS IC , ft. ft F.
.
Facility/Owner Name. Facility IN(if applicable) ft. ft ! •.• t.• a... 1 „ti.r
q rDo(C.t Wee a. Lilt Le t c r bker o' '748 ft ft I 120?4
Physical Address,City,and Zip ?1 REMARKSbanCn (Q 8-1 1 ‘ c V ure Irgtr fi'
County Parcel Identification No.(PIN) '`h'..a3'
fib.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22 Certification:
3S°W/3/P fl �
N � . 't/7 '2 ► 74 " w �e 2 z
SigBatdre of ' ed Well Connacbr
6.Is(art)the well(s): !71'ermanent or ❑Temporary By signingthis forum,,1 hereby cert6 that the well(s)was(were)constructed at accordance
with 15A NCAC 02C.0100 or 15A NCAC WC.0200 Well Construction Standards and that a
7.I,this a repair to an existing well: DYes or 0'No copy of this record has been provided to the well owner
Ifthiss is a repair,fill ad brown well construction brfornration and explain the nature of the
repair under#21 rentmks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: / construction details. You may also attach additional pages if necessary.
For multiple iryecttat or non-water supply wells ONLY with the sane construction,you can
submit one form SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 32%S (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3( 2ff00'and 2@100') construction to the following:
10.Static water level below top of casing: oAO .. (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. y _ (in.) 24b.For Injection Wells: In addition'to sending the form to the address in 24e
Rotary above, also submit a copy of this fnrnt within 30 days of completion of well
12.Well construction method: 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 Marl Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ! 0 Method of teat: Blowing-Rig 24c.For Water Supply&Iniection Welk: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
136 Disinfection type: Chlorine Amount ye oz completion of well construction to the county health department of the county
t where constructed.
Form CW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013