GW1--04163_Well Construction - GW1_20240717

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells .
1.Well Contracbr Information: —
14.WATER•ZONES_
Bobby W. Potts FROM TO -- r DESCRIPTION
Wall Coniractw Nano ft A el 6 ft —
NCWC 2028-A ft ,/C ft
NC Well Contractor Certification Number 1S.OUTER CASING(for mini eased sus)OR LINER Of mplialie)
PROM TO D T MATERIAL
Ferguson's Well and Pump, LLC y (;�,� ft (k_h` 2l6 12•�"—%i �-s�()rL?/ ,
Company Name /� 16.WiER CASING OR TUBING(ptdeb�smal dared-loop)
Ua - b 6�. PROM TO DIAMETER TRIMNESS MATERIAL
2.Well Construction Permit##: ft. ft ia.
Lau all applicable well eorturucdan pumas(Le.Corony,State,Variance,rune,etc.) — --'-
iL ft in.
3.Well Use(check well use): —
17.SCREEN
Water Supply Well: FROM TO DIAMETER MOT SIZE TRIMNESS MATERIAL
❑Agriculhual ❑ ctpal/Public ft ft in.
(Heating/Cooling Supply) CtIResidential Water Supply(dingle) ft ft m.
❑Industrial/Commercial ❑Re idential Water Supply(shared) la GROUT — -
❑Irrigatiom FROM TO MATERIAL_ FILPLt TMETHOD&AMOUPTP
Non Water Supply Well: • 0 , ft. 20 ft Concretes Gravity-Flow
❑Mamitoring ['Recovery ft _ ft —~
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Rcmediation 19.SAND/GRAVEL PACK 6f atrpticabte)
:Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL tooLaceME TMETHOD _
ft. ft.
:Aquifer Test ❑Stomlwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control ' -i
20.DRILLING LOG(attach additional sheets ifaerrrraii
El Geothermal(CIosed Loop) ❑Trans PROM TO (agar,hardsf s,toll/Twit sea de•,.se)
❑Geothermal(Heating/Cooling Rehnn) DOther(explain under#21 Remarks) C ft t(c ft. c6./
4.Date Well(s)Completed; 4/42LtWell MN
t�G it � t ri Q 41 �f `flf.��
Sa Well Locution: • ft 6 L ft �� r ll�(l`G)C1 c.
kf+SI-evivr feud eolx/�S �� � f' S ft.f A/`a uJ MC _ .
Facility/(hvaer Name Facility Mt(if applicable)
ft. f. ,.._ �. L . �.�'
41 ll.t.r)l'S.e Look F +Clio.( '.) '3c ft ft. fin 1 i 2G24
Physical Address,City,and Zip 21.REMARKS
County Parcel-Identification No.(PIN) lit.'.a 3 v,a'r
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:avail 22 Certification:
all Sold,one bit/long is sufficient)
IT 1
_,
,z7z..;_, L‘
Sc. ..:1e of C cd Well (//iaele
6.Is(are)the well(s): 0<rmsusent or ❑Te nporary
By signing this farm,I hereby cede that the well(s)was(war)constructed rn accordance
with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and drat a
7.Is this a repair to an existing well: DYes or ®Tlo copy of this record has been provided to the well owner.
.f Iasi s a repair,fill out brown well construction information and explain the nature of the
repair under#21 rrmonb section or on the back of del:farm. 23.Site diagram or additional well details:
/ You may use the back of this page to provide additional well site rirsaiFe or well
a Number of wells constructed: construction details. You may also attach additional pages if necessary.
For nmltlple irrJactioa or non-water supply wells ONLY with the same construction,you cm
submit one form SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: i;C 5 (ft) 24a. For All Wells: Submit this firs within 30 days of completion of well
For multipk wells list all depths tfdtfferest(=ample-3@,200'and 2@100') construction to the following:
10.Static water level below top of casing: 'I C` ' (ft.) Division of Water Quality,Information Processing Unit,
ff wa ter level is above casing.„Se"+.. 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. i. 4 (n.) 24b.For Injection Wens: In addition to sending the form to the address in 24a
Rotary above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construatiem to the following:
(i.e.sugar,rotary,cable,direct push arc) Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) / Method of test: Blowing-Rig 24e.For Water Supply&Infection'Wells: In addition to sending the form to
the address(cs) above, also submit one copy of this form within 30 days of
13b Disinfection type Chlorine Mannar oz. completion of well construction to tie county health department of the county
where constructed.
Form OW-I North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013