GW1--06831_Well Construction - GW1_20241115

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WELL COIN S'IR U UTION RECORD ' For Internal Use ONLY: ,
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. This form can be used for single or multiple wells
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1,Well Contractor Information: .•
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Bobby W. Potts 14.WATER ZONES .
FROM TO
DESCRIPTION .• • .•
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Well Contractor Name ft. 3
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NCWC 2028-A ft. 'ate040 ft 1 . . • ,. .
NC Well Connactor Certification Number 1S.OUTER CASING(for multi-cased'wells)OR LINER(if applicable)
FROM TO DIAMETER ' THICKNESS. MATERIAL
Ferguson's Well.and Pump, LLC . 0-ft. ' 76.• " 41.2Cir'-• 2/6 d A5- PU65022-/
' Compas3y Name . • . 16.1NNER,CASING OR TUBING(geothermal clusial-loop) - ' .
. FROM . TO DIAMETER THICKNESS .._ MATERIAL' - •
.- .2.Well'Construction Permit#: . a 6,4.t.4 - b ca.3L( . ft. ' ft. iti.
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List all applicable well construction permits 6.e.County,State,Varicezce,etc.) •
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.3.Well Use(check well use): 17.SCREEN
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, . Water Supply Welt' ' '. . . . FROM TO,
DIAMETER SLOT SIZE THICKNESS MATERIAL . .
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02kgrictiltural:' . '• . ' . 'ElIVI, .. 6ipal/Public ft ft in. . . .• •
Ogeothermal(Heating/Cooling Supply) 4esidential Water Supply(single) ft ft. in.
•Olndustrial/Commeicial . 18 GROUT
OResidential Water Supply(shared) . .iliciivi . ' • . '
TO MATERIAL EMPLACEMENT METHOD Sc AMOUNT
OiriigkiOn . • . : ' - 0 ft 20 . ' It Concrete Gravity-Flow
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Non-Water SUpplyWell: •' ' ' . ' ' '. .
. . ft ft. . . . .
bMonitoring . . .., : . bRecOvery • ' . . . .
Injection Well: . . . ft . ft • '
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pAquiferRecharge: : 1 ..•. , • . . . 'CI GrotindwaterReinediation . : 19.SAND/GRAVEL PACK(if applicable) . . .
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0ikquifer Storage and RecOVery. :0 Salinity Hastier . . '. FROM MATERIAL EMPLACEMENT METHOD
' °Aquifer Test '- 'OStOrmwatUr Drainan ' '
:- . ft ft . , -•
DExperimuntal Technology •bSubsUe iden Control '• '• ' , . ' .
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20.DRILLING LOG(attach addilionaisheets if necessarj)v . .
OGeotherrnal(Closed Loop) • OTracer • . • : .•'• : . • • 'FROM •. . .TO•• • • DESCRIPTION(color,hardness.soil/rock typrain its;etc.) . .
OGeothermal(Heating/Cooling Return)• •00ther:(explain under 42.I ReMarki) '0•..ft• 6p. ft - .
• .• 0 ft. . 70 ft: / • •
' a ,-.4i/ ""et.0 •
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4.Date Well(s)Completed: / // .2Y WellIIN• • . . . . .
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5a.Well Location: • .
• ' 76:-6. SOS ft. 6--Pay' ti.71c. ,: . • .. . . • .
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t`)0 Neu-k-ouv.e.:LI.C -.. I I • .fr. . ' . . ft.
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•Facility/Owner Name Facility ID4(if applicable) . . . •
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4.6 l 0 feu.).court e ilQ Le'test& •ap7q861 ft.• . ,ft '7: t •;,',..-..C.,:„:'.1,. :, ', :..:',Li' •• ..
Physical Address,City,and Zip . 21 REMARKS ._ . .
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-lune'nrrklot2 Flet 0 .5c : NOVt40 V 1 74 P • .
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County ‘ Parcel Identification No.(PIN)
. Irf .7. P7,-.,.-2,--... -,,-„,
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: ' C ' LriVi:c.2:''..:.-3 •
22. tifili :
(if well field;one lot/lung is suilleieat) er ca on .
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Si na of C 'Bed Wel Con dor -
6.Is(are)the well(s): '21‘1:arterit or °Temporary . By signing this form,I hereby certi),that the well(i),was(were):constructed in accordance . .
with 15A NCAC 02C.0100 or 1.5A NCAC•02C.0200 Well Construction Standards and that a
7.Is this tt repair to an exiting well: 'OYes or 2‹:.. . copy of this record has been provide-dto tile well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under 421 remarks Section or on the back of this form. 23.Site diagram or additional well 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 necesstuy ., . . .
For multiple infection or non-water supply wells ONLY with the same construction,you can
submit one form SUBMITTAL INSTIJCTIONS. , •
9.Total well depth below land surface: ..30S7 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well :
For multiple wells list all depths if different(example-3(,200 and 2©2100) construction to the following:
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10.Static water level below top of casing: S-0 (ft.) Division of Water QualitY,Information Processing Unit, . . .
If water level is above casing,ine"4-" 1617 Mail Service Center,Raleigh,'NC.27699-1617 • - - •
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11.Borehole diameter: i ..... 6 (i11-): 24b.For infection Welts: In additiOn to sending the forth-to the address in 24a • .
above, also submit a copy of this fbrm within 30 days of'completion of well . .
12.Well construction method: RotarY construction to the following: ,
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(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
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13a.Yield(gpm) . V. ' • Method of test: Blowing-Rig 24c.For Water Supply&Injection Wells: In addition to sending the foim to ,
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the address(es) above; also submit one copy of this form within 30 days of
13b.Disinfection type: Chlorine Amount: -TO oz.. completion of Well construction to lie:county health department of the county
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I - where constructed: ,
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Form CW-1-, North Carolina Department of Environment and Natural Resources-Division of Water Quality • , Revised Jan.2013
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