GW1--06857_Well Construction - GW1_20241115

WELL CONSTRUCTION RECORD a
' This form can be used for single or multiple wells•. • • • . •
:For lntetaal Use ONLY:: I; .
1.•Well Contractor Information: . . . • . • . . ' .. •. •. - . • • . - • . . . .
}I, , . ..14.WATERZONES . . ! ' .
BOui y W. POttS' . ' FROM •TO �•�y r DESCRIPTION .
Well ContractorNnme fk JV I: .
NCWC 2028-A ,ft.. ... ft. :. _..:. ,1. I -- ..
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NC WellContectorCerifationNumber . ..., 11°TfERCASING(foi'multiwedldis)OR LINER Cda''''-ble) ' '
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FROM. .TO • .DIAMETER THICKNESS -MATERIAL
: Ferguson's Well,.and Pump,LL• O • •
d fG' Y3 : (�l� S:'� 2l6:IlA :I�,2/ b'c
Company Name 16.INNER CASING OR TUBING(geothermal:raced-looP). " ' ' -
a- n FROM . TO ' _ DIAMETER •THICKNESS" MATERIAL
.2.Well Construction Permit•#: t U t. '— 000.8 v� • ft.. . ft. m. . . ..
' . .List all applicable well coxrhuclion panes(ce.County,State,Variance;etc.) • .
ft ` ft • '•in- -
' . 3.Well Use(check well use): . . .• . ' 17.SCREEN . .
Water Supply Well: . .. . . . . . . ... . . FROM. TO. .'.- DIAMETER SLOT SIZE THICKNESS MATERIAL . .
tural ❑ rpal/Public it ft. •in
❑Agricul
•
. ❑Geothermal(Heating/Cooling Supply) OResidenhal Water Supply.(single) ft • ft . in. ' .• •
❑lndustnal/Commercial•. .•, • DResidential Water Supply(shared) .13'
GROAT - - - ' '
FROM . TO MATERIAL `, EMPLACEMENT METHOD AMOUNT.
❑Irrigation 0 ft: •20 ,: ft- Concrete, Gravity-Flow
Nan-WaterSupplyWell•, . , . . .
❑Monitoring ❑Recovery. ft. ft
Injection Well: ft": .• ft. : ' .
0Aquifer Recharge.• . . ❑Groundwater Remediation 19.SAND/GRAVEL PACE Of applicable) . .
�A et Story FROM'. TO MATERIAL .EMPLACEMENT METHOD quit ge and Recovery . . ❑Salinity Barrier fk
. DAquiferTest ❑StomiwaterDrainage • .
ft. ft .
OExperimegtal,Technology : . ❑Subsidence-Control ,• : , :
20.DRILLING LOG(amid:.
a additional sheets if l -
t:
srars
.. ❑Geuthermal(Closed Loup) . . ' . .OTracer . . . . • .
. FROM' TO • DFSC'RIPTION(coler,hatdnew,soil/rock type,grain rise,ete.). .
• ❑Geothermal(Heating/Coolin'g Return) ' ❑Other(explain under#21 Remarks). •'© .ft. . 'ft. . e (a lr • .
f . fr . '3S ft 1. .somi s'7 we
4.Date Wells)Completed: 1:A' Well ID# . ' • . 5 .K •rJ3 'ft, i [ .
5a.Wen Lot Lion- cr 2 l i /1 .. , ,rptea(/�c( • . . .
•. • - 7/' ft. 3(O s ft �a w,`t r'-
SJG�y �{'lt 1 1 l Ps•; ., , ft.: ft. k ' .. .
• Facility/Qtvtttlr Name•'•- • ' Facility ID#(if applicable) • c ,p,.i a
tJAtC nt Lt- ild_Q✓ •PP/ O ( • -f`' ft
• 7 NOV l NOV :: � 4
Physical Address,City.and Zip 2L RE114ARK - ' i • . . .
` 11" (Y7117/_ a 1oZ�l.q in , • . Ir .. :,-:..'< el ?-,-,.,,v.,, >_.-..,
•
.County - Parcel Identification No.(PIN) L. e r,, QG -
. . 5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:.:•
. , (if well field,one las/long is sufficient) 22.C.A. ,.7eation:•'
s°C(Y►`0 106 Alf 3. N- 507,d 36. )7, /' i".. . W ` • • •7 I/
.Signature of ad welAZ
::Da '
6.Is(situ)the wells):' ermanent or •.17Temporary By ice this form,I hereby eery*thai the well(s)was..(were)constructed hi accorelance •
with 1SANCAC 02C.0100 or 1SANCAC 02C.0200 Well Condrrection Standards and that a .
7.Is this a repair to an existing Well: ❑Yes• 'or EC< .copy of this record has-been provided to the well owner .
If this is a repair,fill out know?:well construction b oriration anderplabs the notice of the. • .
repair under#21 77M71arksseciion or on the bade 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 , •
S.Number of wells constructed: . .• /.. . . . . . . construction details. You may also attach additional pages if necessary. . . .
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. Form duple ttjeotzonoi•non-water'supply wells ONLY with the sense construc ion,you can
svbnct onefotm SUBIIIITTAL INSTUCTIONS'• ,
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9.Total:well depth below land surface: • ' . '30 . (ft.a. 24a. For All'Wells Submit this form within 30 days.of completion of well
Foimultiple wells list all depths ifdfferent(exmnple=3©200'and 2Q100') • •• construction to the following: - • •' . • . .•, • .
10.Static water level below top of casing: • VO O . Division of Water Quality;Yatarmation Ptricpa6eg Uric, . • •Uwater level•ts above casing,use"+" '_ 1617 Matz Service Ceater,Raleigh,NC 27699-1617 .. .
' .11:Borehole diameter` — . (tn.) 24b.For lnieetion Well.r In additionito sending the tone to the address in 24a •
ROfa.ry, above, also submit a:copy of this form within 30 da}s,of.completion of well
• 12.Well construction method construction to the following: t'•'
(i.e.auger,rotary,cable,direct push,etc.) . . I, .
• Division of Water Quality,Undergrotmd Injection Control PAngram,
FOR WATER SUPPLY WELLS ONLY:'• •.1636Mail Service'Ceater,Raleigh,NC 27699-1636 .' .
. 13a.Yield(gpm) ' - Method of test: Blowing-Rig . ' :24e.For Water Snnnly&Injection iWeila: In addition.to sendingthe form to .
the addiess(es)'above, also submit one copy of this form within:30 days of
• ' Chlorine.' - SOU Oz• complebtion'of•well construction to the county health department of the.county
13b.Disinfection type::. Amount: where constructed
• -: FormCW-1: :• : . . •' North Carolina DepOrtreent of En;iiroomeni and Natural Resources—Division of Water Quality , . ' •Revised Jan.2013, '-