GW1--06790_Well Construction - GW1_20241114

. ..WELL CONSTRUCTION RECORD . For Internal Use ONLY: ' • • • ,: ' '
This form can be used for single or multiple Wells : • • - - • • .
• , 1.Well'Conttsctor Information:- . ''
• Babb W. Potts, • • -14.W -ATEt7ANES,. :: r
M .TO •.. ,• 'DESCRIPTION . .
Well CoatTictor Name' . . ' . . : • '. -ft• .d2II ft . I L . . . . ..
NCWC 2028-A -:- . . . ft : . i ; . .
' NC Well Contractor Certification Number • • • 1S.OUTERCASING(formniti *ens)ORLlNER(fal cshit) .
FROM TO.• • DIAMETER THICKNESS MATERIAL.
Ferguson's Well Pump, LLC • : . o.:ft. j . Gt0s' 21Gi•1.1S• P(/C SP .2/
• Company Namc ' - 16.INNER CAfS�I(POR T(JB NG(reodietmal closed-loon) :
-: FROM' TO ' DIAMETER•- 'THICKNESS' MATERIAL
. . 2 Well Coustr`uetion Permit#: . n.SS ^ a od,(4. 0e1 Li D,•'' . . ' ft . • . ft. ' . ;', in. ' . • - . . '
•List•all applicable well caistrrrctionpenisifs(1.5.Cotvrts,State,-Variance;etc) .
' • 3.Well Use(cheek well use); • ' • • 17.SCREEN
: Water Supply Weil: . . FROM: TO : DIAMETER SLOT SIZE TMCICNFSs , MATERIAL
ft fk fit ..
❑Agricultural ' . . ❑T4funicipal/Public . ' . • , . - •
. ❑Geothermal,(Heatingfl ooling Supply) •DRessidential Water Supply(single)• ft • ft in: - - . • .
❑Industrial/Commercial, •: ,' OUT • • • • ' ' • -
:(]IrriAatioa
'FROM TO MATERIAL EMPLACE
MENT &AMOUNT •
0.' ft 20 : ft' Concrete. •Gravity,Flow .
• . . Non-Water Supply.Wel: • . . . . . . .
Monitoring ❑Recovery ft.. ft
Injection Well :it ft
❑Aquifer Recharge... . `. . .. ❑GroundwaterRemediation-' 19.SAND/GRAVEL PACK fdappiivable) . '
FROM: TO • •: •:MATERIAL• . • . PLACED/PEN METROD. .
❑Aquifer Storage an F.M
d Recovery -- : ❑Salinity Barrier. : • ' . • . . - . .
'❑Aquifer Test. . ❑StormwaterDrainage . : . . _
ft •. ft'
-❑Experimental Technology • ❑Subsidence Control .
• . .20.DRILLING LOG.(attach additional sheets ifaecemars) - •- • •
• ❑Geothermal(Closed.Loop), ❑Tracer FROM .• TO .DESCRIPTION(color,hardness,solUrock type,grain size,eta)
OGeothermal(Heating/Cooling Return) .' ❑Other.(explain under#21 Remarks). ..-.0 .ft .'15. .ft, .. 'C•(i y J: . - . •: , •: -' -
4.Date Wd!(s)Completed: . Well ID# - -.VS.'. e(r ft . • 44w�l/P S 77I u.0"
.' t!.'f`' S'i . ft i'• �� //�coo?! ' - . . . . .
Sa.Well Location: 1 t�f^
- 53 :ft 5-leg ft (itlC..lfic . ,
i�.f _•-'Qlilim'' .. •LL. it' . ft
Factht/y/�LQmerName. • . •
, Facility lD#(if applicable) ' •C• ' ft • .` I,-........',....•a. - /y� o
. . t2 It( .h'l c)ht4i tskr: IW 14: .. Ike ri iii✓S[J/1 t.►Z k c97'i.. .ft: it • : • ' •i' .. ., .N O V :1 ' Z.V Z4
Physical AddiLss.City;and Zip 21 REMARI{S
11en—cr5on q(Da 0gf1(in 1 it �.... �' _-y �,. tt
r Jd3:1 • -.
. -.County . Parcel Identification No.(PIN) ,I ' "' „• •-
Sb.Latitude and Longitude in degreeshninutes/seconds or decimal degrees: .• 22.Certification . • • ' •
(ifwell'field,one lid/long is suilicient) . ' . k :
• •?S ..AD' ?'►b' 2-'I - N' Tx ..3S.zlo:.-gbY_ ' W .: .
� Si of Sea el n for.
6.Is(are)the Well(s):.CIPermanent: or ❑Temporary' • • • .'• B3'signing fins form,i hereby certify.that the well(sj was(were)constructed in accordance
' .` with TSANCAC 02C'.0100 or ISA'NCAC 02C.0200 Well ConsttveionStandards and that'a '
• 7.Is this a repair to-an existmg-welh• ❑Yes • or '•�No• .. •. . • • copy ofthts record has been provided to the wel owner.. . • • •
• . rats is a rrpatr,fill out(brown well construction b forination anderglain the natwe of the -' • ':• • .
repro wider#21 remarks section or on the bac c of thisfonn 23.Site'diagram or additional Well details • ,
•/ • : - : You may.use the back of this page to.provide additional well site details or well :
. S.Number of wells constructed: ( ' ' . : • • 'construction details.•You may also attach additional,pages.linecessary. •
- For»mlh'ple injection or non-walersuppp wells ONLY,with the same corutrsce on,you:can • .• . I '
sabu tarefares [ SUBMI'ITAL'INSTUCTIONS ..
9.Total well depth below land surface: •' ' 7 S - (ft,) •24a. For All'Walk:. Submit this,f Within 30 days of'completion of well
Fornedirpie wells Alt all•depths.iflffeiort(exanple-3@200'and2@100) . ' .• : .... . :construction to the following: . ' . ' I .
• 10r Static water el below-top of casing . 6... . ' •(ft.) . '• Division of Water Quality;Information Processingg Unit, , -•
7f sitter level is above casv:g,use"+" ,. ' ' •1617 Matz Service Center,Raleigh,NC 27699-1617
•
IL Borehole'diameter. (an.)• • • 24b.Fan'Iniee.tion Wells:, In addition to sending The form to'the address'in 24a
• Rota • • .- above,.also:submit a.copy.of.this'form within.30 days of completion of well - .
' 12.We lconstruction method: rY .• construction to the following:
(i.e.;auge r rotary,:eabIc directpusl;etc.). •' ' Division of Water Quality;Underground Injection Control Program,
i.
FOR WATER SUPPLY WELLS QNLYi ' ' ' • • • •'• .1636 Mail Service Center,Raleigh,NC 27699-1636 . -
13a.Yield • - ' .Method of test: Blowing-Rig 24a For Water Supply&Iniectioa 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.: .dun • .y$ :. , , o•z. • completion of well construction to tlie'county health department of.the County • . ,
• where constr.ucted.
• =Form I_ ' • . - ', Nor*Carolina,DepartmentofEavimnmeatand:NaturalResources-Division of Water Quality', -Revised Jan.2013 . •
.