GW1--06787_Well Construction - GW1_20241114

.WELL-CONSTRUCTION RECORD ForinternalUscONLY: • !
- This form can be-used for single or multiple wells ' '
•1.Well Contractor Information: •
14.WATERZONES •`• . . ••.•I' . •
Bobby W. POttS FROM- ' TO r DESCRIPTION ,
• Well Contractor Name . it
. NCWC 2028-A • rt ft , f l' .'
NC Well Contractor Certification Number • . 15.OUTER CASING(fozIImlfi-iased'svdls)ORUNFREE an ) • ' ..
PROM ' TO L DIAMETER.t II THICKNESS MATERIAL" • .
Ferguson's Well Pump, LLC • - 0:ft 60 ft (i•t 5'A' b'ik/IA5: fa' 0/22/
Company Name 16.INNER CASING OR TUBING.(ssukbeemal closed-lool). '
FROM. TO '• DIAMETER -THIC E NESS MATERIAL -
.• 2.Well Construction Penult#: �M Q - 3 Lt-1 k) - • ft . . i iR . . .. . . ' . • .
List all applicable well construction permits(ce County,S1ate,7rarim:c4 etc.)
it it 1
3.Well Use(check well use):,- . • 17.SC1 EEN , .
Water Supply Weil: . FROM . TO DIAMETER' .SLOT SIZE : THICKNESS' MATERIAL .; . '
❑Agricultural ❑ paUPublic • it ft
❑Geothecmal.(Heating/Cooling Supply) deential Water Supply(single) - ft •• .it • . in! '
•
❑IndustriaUCommercial• ' • • ❑Residential Water Supply(shared) 1&GROAT • -
. PROM . TO . MATERIAL . EMPI.ACEME NTMETHOD e.AMOUNT .
❑l nigatioa 0 fa, 20 ' aConcrete.' Gravity-Flow. .
Non-Water Supply Well: - •
❑Monitoring ❑Recovery ft.: ft , . .
' Injection well: .ft ft. .
•
• ❑Aquifer Recharge DGroundwater Remediation : 19.SAND/GRAVEL PACK Ef armLe) .
❑Aquifer Storage and Recovery ❑Salinity Barrier.• . . FROM TO ft. ft MATERIAL i 'EMPLACEMENT METHOD
•
❑Aquifer Test ..❑Stormwater Drainage, ..
• ft ' ft 1••
• ❑Experimental Technology,- - ❑Subsidence Control .. r .
. . 20.DRILLINGLOG.(attachadditio alabrs sifneeess:ar9) `
❑Geothermal(Closed Loup).. . . . .❑Tracer FROM- TO DESL'IRPTION(color.bardnexs,solltroclt type,grain use eta) • -
' ❑Geothermal(HeatinglCooling Return) . °Other(explain under#21 Remarks)- . 0 ft i O 'ft I'C)a ,
�a y y� ft s, •ft • �aYs N�•
.
4.Date Weil(s)Completed:. well ID# �
Sa.Well Location: •
S S ft 6 04. i. /Cat Or/C
r 1 60 fuss rt i; ; w,t fe.
Lcet st ( . Wost-f tCAot) ft: ft - -,;-
Faciliti O nerName.• : FacilitylD#(if applicable) ft !T�•::::
_• __ ':;
LpR,).�11a�to. \ iy ' Q Ca )-tf✓1 4,9:P1 ( :ft' : ft •
1
' • NOV f 2024
Physical Address,City and Zip 21.REMARKS
/—Ayli)O0J • 6(011-66 -c 't35 ll.v: 7� �
County Parcel Identification No.(PIN) •
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:': .22 Certification: ,.i;. .
(if well field,one lat/long is sufficient) • - - • .
•
sS°3�.`'salglig, elv 2..s V7� yvf 73etA w ' •• �;
• Signature ofC 'fled Well Contractor• • • ' . . a
6 Is(are)the�veli(a):•@Permanent or ❑Temperary fly signing this,lorm,I hereby certify 6rat•the well(s)was(were)canslructed in accordande
• with ISA NCAC 02C.0100 orISANCAC 02C.0200 Well Construction Standards and thai a .
7.Ls this a repair to an existing well: ❑Yes or. 2'Nu ' copy of this record has been providedto the well owner.
• If this is a repair,fill out loiown well construction infor'ualion and explain the nature of the
repair:outer#21 rmnarks section or on the bade ofthtsfonn. 23.Site diagram Or additionalwell 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 multipielrgectlas or non-water supply wells ONLY with the same construction,you aan '
submit mseforn . SIJBMIITAL INSTUCTIONS i '. '
1 • •
' 9.Total well depth below'land surfacer O S (ft). 24a. For All Wells: Submit tliis form within 30 days of completion of well
• For multiple wells list all depths ifdifferent(example-3Q200'and2@100) ' construction tothe following:
I. ;
(' '
10.Static water level below top of casing: • • •. ' (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: i ' 4 (in.) 24b. 'or'Giieetion'Meth: In addition to sending the form to the address in 24a
. above, also subinit a copy of this form within 30 days of completion of well
ILWell construction method:•Rotary, construction to the following: 1, ,
(i.e.auger,rotary,cable,ducet•push;etc.) , . , • • r
. Division of Water:Quality,Underground Injection Control Pmgrani,
FOR WATER SUPPLY WELLS ONLY:' 1636 Mail Service Center;Raleigh,NC 27699-1636 '
' • , Blowing-Rig • 24c.For Water Stmnly-&Iniectl Wells: In addition to sending the forni to
13a.Yield(gpm) y •- Method•of testa • g g
the address(es),above, also subinitl one copy of this form within 30 days of -
136 Disinfection type::Chlorine •Amount- 70 • OZ. completion of well construction tolthe county health department of the county - -
-where constructed. .
• i
.
Form CW-1. North Carolina Department of Environment and Natural Resources-Division of Water totality Revised Jan.2013 •