GW1--06792_Well Construction - GW1_20241114

WELL CONSTRUCTION RECORD • , .
•This form can be used for single or multiple wells • For Internal.. • •'e• Y: -
. • 1.Well Contractor Inforntatiun: - : . ' • . ; - •• • • . . • .
• Bobby'W. Potts... • - . • . . .: ia.WATERzoES'.:• . . .1 ..
.
• •
. . . . . . . . FROM. TO '. .DSCIPION . •
• Well ContraotorName . .. . .- . . '. . ' ' . . . .'. f • o ••ft.. . •• . IT . . . . . .
NCWC 2026-A .' . •.' •' ft. •' ft. I . : •
.
- 15.OUTERCASING(formulfitased wells)ORLINER(if ble)
NC Well Contractor Certification
FROM TO• I DIMMER • THICKNESSMATERIAL
' Ferguson's WeII.and Pump, LLC • : • •. • • . ey,ft., , L(6r 9,j I fill 2/hc/AS• • t/C5T/22d
Company Name . . • '. SE'16.INNER CA G ORTU8INNNG othsrmal eliaed4oup) :,
FROM. TO• •: :•D :• • .THICKNESS MATERIAL - • .
2.Wel.Constrnetioa Permit#:. 0.5 S - U a t-i.- •'Cj L(.7j.3. . .• ' .ft . .. ft , :in.• . . , •.. . .
'List all applicable well corisi uchon permits(i.e.Cototty,State,'ariance,etc.) •'. • -' '
it ft. 1
• •3.Well Use(check well use): • . . • :
Water Supply.Well: . : • . . . ' ' FROM:• TO DIAMETER SLOT SIZE THICKNESS MATERIAL -
❑Agrieultt sal cipai/Ptiblic ft ft is . . .
. • ❑Geothermal.(Heatin Coolia 1 ' • .-• dential Water Su (single). • ft' • .•it in.
• . •
g� g DPP Y) PPIy' . • .. ❑Industrial/Commercial. . . . DResidential Water S•u shar ' 18.GROUT -
. . ' ❑Irrigation . . &
pPl)'( �•: FROM -TO MATERIAL EMPLACEMENT AMOUNT. •
Non-WaterSupply.WeII: 0•: 1 ft. 20 Concrete' . Gravity:Flow ,
❑Monitoring • 7Recovery . ' fa: ft ..
•
:Injection Well: •• . • . . fc ft . .
•
❑Aquifer Recharge:-'' • D Groundwater Remediauon' ' 19.SAND/GRAVEL PACK Cd ao dieable) • • '
. . .
" FROM' TO MATERIAL FSr�LACFl4�1rfI1�TIiOD
•❑Aquifer storage andRecovery .• ❑SabnttyBarrier :' :. • '' - i - •
• . '❑Aquifer Test. • . ' - ❑Stoimwater Drainage. . • . . - •ft' ft' . • • '
:❑Experimeatnl Technology'• . • ' '❑Subsidence Control ...• i, . •
20.DRILLING LOG(attad additonal sheets f ssas9) • .'. . .' . '.
QGeothal(Closed Loup) ❑Tracer :•
FROM.• TO .DVctRrIPTTUN(valor,dvdoess,solUroclt type,grate the,etz)
'❑Geothermal(Heating/Cooling Return) •• OOther(explain under:#21 Remarlts) . .: d•ft• :�0.' :ft . .is,l ay . . •. . . . . •
-::: : m
WellIll# • • l. t i'lJ �-
Gj 1-v t Ct✓i' .• to r,7 S ' . . :• • 71 ' Lf t�� t^It W li 1{`e
. CG tl 'ft.. • ft'
• ' Facility/OwnerName . • • • . ' • Facility lD#(ifapplicable)
[' ft ft 4 t i,.,3,
10Lt. 'S� .1-<2ke• .0Yeve•' •Ver1�Y a-tuij1 a79o.• .. ft: ., • ft ! • • • 21174
Physical Address,City,and Zip . . . 21.REMARKS - . ' . ' . . .
. . . . • ( �-l.er)�erSo Y, - . • " • � � l•� a.� i(n3a' - , •!. .lr,f.:...:.., - ? -- , `� :;
County Parcel ldeetificatioallo,(PIN) • • . {1,r:"v'..'f;'s,-%-;:i ' .
'Sb.Latitude and Longitude is degreeshniauteslseconds or decimal degrees: :• ti ti a , •
(if well field,one lal/long is suficieat) 22.:Cerfieaoa '
•
S 6i�S•i .0 r' .'X X tl TV': a �7 rlt r. "S/�s ' •r. W.
. ' ,/(C/i.fi�t .•liellg* JL t ••• .
actor
. ':6:Is(are)thewel(s) eat or' .❑Temporary ' ' ' - .By,signing this form,I hereby ceiiify that•the wells)was.(were)constructed in accordance •
' with'ISANCAC 02C.0100 or ISANCAC 02C.0200 Fell Canstradio:Standards and that a • '
• 7.Is this a repair to an esistmgwell: Dyes• or l 1 o - -- copy of this record has been provi�d to the well owner. • • -• ,
. 'If this is a repair,fill out blown well construction bforinalion and esp141n the native of the • •' • .
repair ender ti21 r sertfon or on the back of thisform. . 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 if necessary. '
For multiple hjerrtlonor non-water supply wells ONLYwith the sane construction,you can' • . : -
' sube it onefom»z' .• - • SUBMITTAL INSTUCTIONS-• 1'-
. - 9:Total well depth below land"surface: y,� '" • • (ft.) 24a. For All Wells: Submit this,form:Within 30 days,of completion'of well
• . For multiple wells.list oll.depthss.fdlffereit(exaraple-3Q200'dud 2Q100') .' . : . • .• constriction to the following: ' ` . .
•10.Static water level below top of casing: ' V(/. . (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: .*.` (in.) 24b.k'oir inieetinn WAS: In addition to sending the form to the address in 24a
.. . . .. . above,.also submit'a•copy of this',form within 30 days.of completion of well • ..
12.Well construction method: Rotary ::; ' , • : construction to the follovaing: , _ p. . .
(i.e:auger,rotary'cable,direct push,etc.) I; . '
' . ' • ' ' . ' • Division of Water.Quality;T3adeigrouad Injection-Control Program,
FOR WATER SUPPLY WELLS ONLY: •. ' • - . • '- 1636 Mail Service Center,Raleigh,NC 27699-1636
• •BIowin -Ri 24e.For Water Sapnio&7niectioia' Wells: In addition to sending the'form to •• • • '
13a.Yield'(gpui) : I . Method of test: g •. - . :. .. the addresses)above, also.submit one copy of this.form within•30 days of
13b.• •Disinfection type: Chlorine : .• am•
ount:::. ' 'VAC • :oz.,. completion of well construction'to the county.health-department of,the county „ .
_,where constructed. it.
' . Form GW=1•;• • . '. . North CamlinnDepartment of Environment and Natural Resources-Division of Water Quality ,. , Revised Jae.2013. . •