GW1--04184_Well Construction - GW1_20240717

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells I
1.Well Contractor Information:
Bobby W. Potts �oWATER•ZOM TO • DESCRIPTION
Well Contractor Name H• • 5/C. ft
NCWC 2028-A ft 3, t f
NC Well Contractor Certification Number • IS OUTER_CASING(far a eased wdl,)OR liNER(d app&sl e)
_ FROM TO DIAMETER THICKNESS MATERIAL
Ferguson's Well and Pump, LLC l ft. yr ft t r y" .,/A)'ir-<sr 2zi
Company Name • 16.INNER CAM,TG OR TUBING(tuleut>wtmal dosed-loop)
.. J FROM TO DIAMETER THICKNESS MATERIAL
IWell Construction Permit#: 4 11 L{1 ft ft. in. —
Lisi all applicable well construction permits(ie.County,Stoke,Variance,etc.) — -- —
ft ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: PROM TO DIAMETER_ SLOT SIZE THICKNESS MATERIAL
ft ft. in
❑Agricultural ❑'cipal/Public
❑Geothermal(Heating/Cooling Supply) QResidential Water Supply(single) ft ft m
Olndustrial/Commercial ❑Residential Water Supply(shared) 1S.GROUT -
FROM TO MATER]AL ' EMPLACEMENT METHOD&AMOUNT
❑hngation - 0 ft 20 ft Concrete! Gravity-Flow
Non-Water Supply Well: • — —
❑Monitoring °Recovery
it it
Injection Well: ft ft
❑Aquifer Recharge 0Groumdwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL_ EMPLACEMENT METHOD
❑Aquifer Storage and Recovery 0 Salinity Barrier —
ft. ft
°Aquifer Test 0Stomtwater Drainage — —
ft. ft
°Experimental Technology ❑Subsidence Control
-
20.DRILLINGLOG.(alladt additioaal.sheeta trnecesary)
OGeuthermal(Closed Luup) ❑Tracer FROM TO DTSCRIPTION(co►or,hardness,soWUrech type,grain des,sic.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) y 0� 3 fb Zi .
a IL
4.Date Well(s)Completed:/yR V Well ID# .y
).S ft ei ft• • co.c/c-
Sa.Well Location: .
Cr
Sri - 4)ts--1 ,I L "'R YOS � �':�t(N; C
Facility/Owner Wme Facility ID#(if applicable) •
ft. ft.
IQPI V to .1-(,t a h Dr L.-tie oil a f,9‘a 0 a8-s 3 ft. ft . ►... .. ,/ 1 .1
Physical Address,City,and Zip IL REMARKS
ill Pei Ca) et715 3676,-/ o —
County Parcel Identification No.(PIN) , r-rry44''.1(ill
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: D'!►'..a'3v03
(if well Sold,one tat/long is sufficient)
22.Certidlcation:
3SDY5'A4t Ydt7. ,� N /���% zy7,g7L Y' w j4, /(/'
-1../..-t. ..-, ..
t�ture o 5ed Well Con for to
6.Is(arc)the wicks): refrainment or °Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 1SA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Consnuctior Standards and that a
7.Is this a repair to an existing well: °Yes or ❑Nu copy of this record has been provided to the well owner.
If this is a repair,fill out known well corubvctiot information and explain the nature of the
repair wider tt21 remarks section or on the back of this fonn 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site dr•tsi1 or well
S.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple bgectkn or non-wafer supply wells ONLY with the sane construction,you can
submit one fonn SUBMITTAL INSTUCTIONS
9.Total well depth below land surface i2.71.,S (f.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(exanpk-3 0'and 2Qa 100') construction to the following:
10.Static water level below top of casing: 3/) (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. t _ 6 (in.) 24b.For Injection Wells: 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: 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 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) , 0 Method of test: Blowing-Rig 24c For Water Sunnily&Injection Wells: 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: VA oz. completion of well construction to the county health department of the county
where constructed.
Form CW-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013