GW1--04160_Well Construction - GW1_20240717

WELL CUN,'1'RU Cl'IUN RECORD For Internal Use ONLY:
rued
This form can be for single or multiple wells .
1.Well Contractor Information: _
-
Bobby W. Potts 14. M.
�T . i DESCRIPTION
mtrao Wall Cotoi Name ft '.2' : n _ .
NCWC 2028-A n ft
NC Weil Contractor Certification Number 1s.OUTER.CASING(Tor mnitretsed wells)OR LINER(d )
. PROM TO DIAMETER THIS MATERIAL
Ferguson's Well and Pump, LLC .0 `Ji.) 1 »t,.A5 id 24//As- pc`c>r `2/
Company Name . 16.INNER CASING ORTIMING(motheemal dosed-loop)
3 8b FROM DDIAMETER THICKNESS , MATERIAL
Well Construction Permit#: r75 U(1 -C)6 ftn in.
List all applicable well ant:ruction permits(Le.Cow y,State-Variance,etc.) --
n ft. ills
3.Well Use(cheek well use): 17.SCREEN
Water Supply Well: PROM TO DIAMETER ri1.0T SIZE THICINEIS MATERIAL
❑Agricultural ❑ al/Public ft ft in. i,
~
❑Geothermal(Heating/Cooling Supply) Water Supply(singly) ft ft in.
❑lndustriaUCommercial °Residential Water Supply(shared) 18.GROUT -
FROM TO MATERIAL. ' Eiftc oMTNT METHOD a AMOUNT
❑Irrigation '
Non Water Supply well: • 0 , ft. 20 n Concrete ___,Gravity-Flow
❑Monitoring ❑Recovery ft. ft --
Injection Well: n ft 1
❑Aquifer Recharge °Groundwater Remediation 19.SAND/GRAVEL PACK Of aFplicabg
❑A er Storageand Recovery FROM TO MATERIAI. EMPLACF�TI METHOD
quit very 0 Salinity Bather ft. ft
°Aquifer Test ❑Stonnwater Drainage ft. ft
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OExprrimemtal Technology °Subsidence Control / -'
20.DRILLINGLOG.(attadr addillemsd sheen ifnenrasaA
DGeuthe:mal(Closed Loop) °Trager FROM TO DFSCRipTt0N(color,bar'daesc soil/rock s'ke,eTa del
❑Geothermal V(Heating/Cooling�Reuan) ❑Other(explain under#21 Remarks) c': it. 1,6 • �w i(t Y)
4.Date Wens)Completed: %7 A well ION L rL CT-� h a✓( S�
sa wen Locator: • , 75 ft J C2 iti A C
Facilitfy/1Ow ne7ii
nerNamc FacilityM (if applicable) ft ft -"• • -A--- 1f*,r 4.
f�('1 F 4 (n Jrt'e1C ehwch eel_ (t)rlt.l.iUsi(t A7$7i ft. ft „ ', 1 7 ./,.'
Pteisical Address,City,and Zip 21.REMARKS
----B unr On)t) c c1 1q11414 b`?Ryrna) 'M
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if wall field,one larpong is sufficient) 22.Certification:
3-V4.4/ y/ i/X% N i-y ; y' �re ,117-s - w / j ? i
S of 9245ed Wel r ,il_r_b_y___
6.Is(are)the well(s): 11Permsnent or ❑Temporary B,signing this font;I hereby certify that the well(s)was(were)c sdructed to ecord ace
�_� with 1SA NCAC 02C.0100 or!SA NCAC i 2C'.0200 Well Construction . lards and that a
7.Is this a repair to an existing well: ❑Yes or ldlvo copy of this record has been provided to the well owner.
If this is a repadr,fill aid blown well construction information and explain the nation of the
repair under#21 remarks 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 d&tails or well
S.Number of wells constructed: / construction rlrtnils. You may also attach additional pages if neragary.
For pe b �
gec orn non-water supply wells ONLY with the stone construction,you can
submit onef AL INbT[TCTIONS
9.Total well depth below land surface: %r (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
Far multiple wells liv all depths tfirercxt(example-3@)200'and 2(4100') construction to the following:
10.Static water level below top of casing. YC1 ' (ft,) Division of Water Quality,Information Processing Unit,
r water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 8 ` (/Q Cm.) 24b.For Injection Wens: In addition to sending the form to the address in 24a
Rotary
W above, also submit a copy of this farm within 30 days of completion of well
12.Well construction a method: construction to the following:
(La auger,rotuy,cable,direct push,eta)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Contra,Raleigh,NC 27699-1636
13a.Yield(gpm) Au u Method of test•. Blowing-Rig 24c.For Water Supdv&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 Aunt 3 ;� oz. completion of well construction to the county health department of the county
where constructed
Form C W-I North Carolina Department of Environment and Natural Resources-Division of Water Quaky Revised Jan.2013 •