GW1--06799_Well Construction - GW1_20241114

VVLt UL, LU1V0 lit UL.IIU1V Kn,...U1K1.1 For Internal Use ONLY:
This form can be used for single or multiple wells ' .
•
1.Well"Contractor Information: . - • '
14.WATER ZONES
Bobby W. POttS FROM TO DESCRIPTION
Well Contractor Name ft , 0 ft i
NCWC 2028-A ft l ft. 1
•
NC Well Co uractor Cartitication Number 15.OUTER CASING(for mild-cased wills)OR LINER(if applieable)
FROM TO • DIAMETER ' "THICKNESS• " MATERIAL
•
'Ferguson's'Well and Pump, LLC 0..,.ft .-gd, ft 6, } in. 2/67/,'5'PK5h-/AZl.
Co a Dame• 16.INNER CASING OR TUBING(geadterinal dused-loup) •
•
t I I FROM "ft TO ft DIAMETER THICKNESS MATERIAL "
Wei1'Constiuction Permit#: I; C.f ! m' -
list all applicable well construction pemtits(i.e.Cotmry,State;Variance;etc. " •
ft. ft • in-
3.WelI'Use(check well use): 17.SCREEN • • -_
• Water Supply Well: . '. • ' ' ' -FROM TO. DIAMETER' SLOT SIZE. . THICKNESS MATERIAL _'
❑Agricultural. ❑Mot''pal/Public ft ft. un .
.❑Geothemal(Heating/Cooling Supply) esidential Water Supply(single) ft ft ' - - ,
❑Industrial/Commercial ❑Residential Water Supply.(shared) 18.GROUT
FROM • TO -MATERIAL EMPLACEMENT METHOD&-AMOL'ICI
-. ❑hiigetion. ." • 0 rt '20 ft Gonsrete Gravity--Flow
• Non-Water Supply Wall: •
.❑Monitoring ❑Recovery' - ft it
Injection Well: ft. . ". ft. • ' .
DAquifer Recharge ' ❑GrouIldwater Remediation 19.SAND/GRAVEL PACE (if applicable) . .
: . . ' ❑Aquifer Storage and Recovery .. .❑Salinity Barrier FROM TO MATERIAL EMPLACEhg Ta ETHOD
• ft ft
• OAquifer Test ❑Storriiwater Drainage -
ft. ft.
❑Experi dental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)'
QGeuthennal(Closed Loup) ❑Tracer FROM ' TO DESCRIPTION(color,hardness,soil/rock type,grain size,ac)
' ❑Geothermal(Heating/Cooling Return) . ❑Other:(explain under 421 Reuiarks) 0 f,t. 6 0- ft ' ,e.( -
4.Date Well(s)Completed: /O( 7 .YWell IDn . �l� ft, . :'75 4. 1 5-a r S'49 r
75_ft i ft t /�/?(7�/J�- _•
Sa Well Location. . ' . , /5ft " +L�a�tra�l`° G
Phitit d5fC11iQ t,vebb rt !
ft
.Facility/Owner Name .: Facility ID4(if applicable) it ft
R Q : ollfa net CrCd.C• r2d Mats (-It' $ 0.87$i ft • ft NOV I 2024
Physical Address,City,and Zip . . 21.REMARKS.. .
_ _ _�1'56n • .1 7tov-I (9 70 iri`:;:;,,.;.. . . _;J u•.,t,r
County' 'Parcel Identification No.(PIN)
•
5b.Latitude and Longitude in deag ees/winuies/seconds or decimal degrees: 22.Ce tificafi•n. ,
(if well field,one lat/long is sufficient)
/
3 S C ry,3'.o2 7, C{j(¢g t N q •2 J�y
1�/55 u l W r/0/2'y/x
� Signature o Certifi ell Con for ; Date .
' 6.Is(are)the well(s): .f'J'Permanent or ❑Temporary Bysi this form,I herebycer that the well(s)was(were)"constructed•in accordance
:ems, f lift' .
with I5A NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
' 7.Is this a repair to an eaistirig well: ' ❑Yes or • No • copy of this record has been provided to the well owner. '
• • If this is a'repair,frll out/mown well construction*n formation and explain the nature of the • ' ' -- '
repair under i121 remarks section or on the back of thiSform. -23.Site diagram or additional well details:
f ' You may use the back of this page to•provide additional well site details or well
8.Number of wells constructed: - . f,' . • ' . . .construction details.'You may also attach additional pages if necess•,uy. -
For multiple iiyection or non-water supply wells ONLY with the same construction,you can • '
submitoneforma - SUBMITrAL.INSTUCTTONS . ,
9.Total well depth below,land surface: " A 6 S. " . (ft.) 24a. For All Wells:, Submit this form within 30 days of completion of well •
For multiple wells list all depths if different(example-3Q200'and 2(3100') construction to the following:
10.Static water level below top of casing: " Yo • (ft.) Division'of Water Quality,Information Processing Unit,
If water live!is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617 -
11.Borehole diameter: v _ (- (in.)' 24b.For Injection Wells: In adiiition.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: L 1636 Mail Service Center,Raleigh,NC 27699-1636
I
i3a Yield.(apm) l nn J Method of test: BIOWItIg-Rig 24c.For Water Supply&Injection 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 Amount: 3 O QZ,' completion of well,'onstruction 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
I )