GW1--06856_Well Construction - GW1_20241115

WELL CONSTRUCTION RECORD •,, - ForInternal:UseONLY:
This form can be used for single or multiple wells - • • -
1.Well Cuntractorinformation: • h' •
Bobby/VV. P.otts. 14.W_ATERZOINES_ .. . i
FROM. •TO f• DESCRIPTION -
Well ContraetorName - . •.. .. .
NCWC 20267A . , . • "ft ft' i -
NCWe1lContiaeoorCertificatioaNumber 15.OUTERCASIlNG(formnitt�ed Wells)OR LINER fifa ) • '
.' FROM • TO'• : _DIAMETER ! THICKNESS MATERIAL.
Ferguson's Well.and Pump, LLC - . oft 6.3 l ft. to,.2S' 2/6r0S /uc, /a/.
Company.Name • • - • • • • - R
• 15.INNER G O TUBING ooA .
- FROM TO , ll 'THICKNESS' MATERIAL
2.Well Contraction Permit#: :o't.ba"3•— w (q p .ft . . . ft . ;.m.. . . ' .
'List all applicable"well construction pertirits(e."Couni,Stag Variance,etc) , - -
3.Well Use(check well use):
- ft.. ft• 1 m
•
•
• .- • •
.• ,. " . .,
Water Su Well: FROM.. TO DIAMETT'R SLOT SIZE •THICKNESS _MAMMAL '
PPIX. - ,
OAgricultural' O ipaLPtiblic it ft ire ;
." DGeothermal.(Heating/Cooling Supply) • •. esidenfial Water Supply(single). tt i f m' . " • - . •
Olndustrial/Commeroral-•-: 'DResidential Water Supply.(shared)
Y l . 18.GROUT
-' FROM.'• : •TO •._• MATERIAL ' EMPLACEMENT METHOD&AMOUNT
OIirigation•
Non-Water SuPP$'-Well: - 0 .- :ft' -20 ft Concrete. ..• Gravity-Flow .
PMonitoririg. . . - ORecoveiy . , ft.! _ . ft • .
Injeetion.Well: :ft: ft
OAquifer Recharge .': •- ----. ❑Groundwater-Remediation • ' 19.SAND/GRAVEL PACK if amSicable) .
DAquifer Storage and Recovery' - - . DSalinity Barrier - :
FROM" TO MATERIAL^� FI PLACEMENTMErHO))
eR" ft;
. °Aquifer Test • " . OStonnwaterDiainage_ . -" • . •
' . • -OExperimentalTechnology • . ' - DSubsidence Control ' R" ` 'ft • . : • ' ' f:
20.DRILLING LOG(atta h additional aheedsifn )
'OGeuthennal(Closed Loop) OTraoer - FROM TO .DESL'RIPTION(color,hardness,salUrorlt type,gFaln rlxa etc.)
OGeothermal(Heating/Cooling Return •' OOther(explain under#21 Reins&'). ,. . ' . : : •• • '
'�.ft• ;�� ft
•
.4.Date Well(s).Completed: /2Y Well III• • • G f t s S f t 5�, , • . „[ • � '
5a.Well'Location: . /
IJe Nl e(S v�. 03:ft Et. ,
Facility/OwncrName Facility ID#(ifapplicablej .
In 5 f t'►')Ij r t'f c e LL.) •1- : •t-A*Jr l/tt_l . .ft. ft : I e r t .` �w..,, 2..:'i, ,
Physical Address,City,and Zip-r : '. - 1` /;
2L12EMARIfS r'Q V �U2
County Parcel Identification No.(PIN) iir • p • ;, .
b.Latitude and Longitude in de /minutes/seconds or decimal d '. ' ` `'' "
� �� degrees: 22.'Cer ti fication:
(,Ewell"field,one laillong is sutEeient)
• . " 5o .AY.Q33/ - .N` . 4e2 2/'S 7,GY67' W,• " �' a . • • .
. Signature o`i� Well•Contractor.- i",_. , . . - • .
• . .6'.Is(are)•the w•ells):' . ermaae•nt. ur OTetaporary • . : '
. By sigrmug this form,Ihereliy"certify.drat the weA(s)was(were)�consJruc(ed m accotdmrce .
with 15ANCAC 02C.0100 or 15ANCAC 02e.0200 Wel:ConsttuctionStwtda ds and that a
7.Is this a repair to•an misting well:• OYes • or EdiVu • • copy of this record has been provided to dte;well owner.• •' •• ' • ' " '
• . 'Ifthis is a repair fill out blown well construction irfonxafion anderplain the name of the - "' • • ' " •
' repair wider#21 remarks section men the backof thisfoim. . 23.Site diagram of additional well details '-
• ' •• ' • • You may use the back of this page AO' additional well site details or well :
S Number dwells constructed: ' construction details. You may also attach additional pages if necessary.
For nraltipleirfectio i ornou water supply wells ONLY with the same cottstruation,you can' :'' r, : .
srtbirat onefoms SUBMLTTTAL INSTUCTIONS
9.Total well depth below land surface: • a" S ' ' (ft.) ,24a. For MI Wells: Submit this form Within 30 days of completion of well
:For nmltiple wells list all depths,Ifdri erent(exanrple-3(a 2 0'and2Q100) :construction to the following: I. •_ : •
10 Static water level below top'of casing '• , 5 0 .. (ft,) '" Divisioti of Water Quality;Information Processing Unit,
' ,If water level is above casing use"+ , " "" " " .. 1617 Marl Service Center,Raleigh;NC 27699.1617 '
II Borehole diameter,.: -- y ' • " (in.) ' 24b.For infection Welts: In addition to sending the form to the address'in 24a .. : .
RUt• •. .• "above,.also'submit a:copy-of this'ftum within.30 days of-completion of well •
12.Well construction Method: . construction to thefolloaing: . . .
(i.e.:auger,'rotary,cable,direct push,etc.). - - - -
• Division of Water Quality;Underground Injection Control Pragr am, ' '
• FOR WATER SUPPLY WELLS ONLY: .. . •-- - •. • ' . .1636*ail Service Center,Raleigh,NC 276994636 " .
13a.Yield.(gpm) •G Method• test:",Blowin• g-Rig- " 24e.For Water Snarly&InieetioiiWells::In addition tosending the.foim•to
. the•address(es) above,also.submit one copy of this.form within 30 days of
131i Disinfection type: Chlorine• Amount: • LD . . .OZ completion of well construction"to-the!county:health department of the county' , ."
•
(i .where constructed .
Feria W-1 " Noah Carolina Deparpnent of Environment unit Natural Resources—Division of Water,Quat ity . . Revised Jan.2613• • •
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