GW1--06861_Well Construction - GW1_20241115

WELL CONSTRUCTION RECORD • . • .
This form can be used far single or multiple wells ." . . • . , For Internal.Use ONLY: • • '
•• I.:Well Contractorinformation: • . . • • • • :"
' . Bobby W. Potts., ... - WATER-ZONES, r • DESCRIPTION
ON . .:
•
Well Contractor Name ft 1•��. ft f.
' NCWC 2028-A .:: • • • - .: . . ft. 170 ft. • I. 1 "
• NC Well Contactor CertiftcationNumber• 1S.OUTERCASING(for multi-easedtvells)ORLINER(if ap uaMe)
' FROM- ' TO DIAMETER f THICKNESS MATERIAL
Ferguson's Welland Pump, LLC • , '. d-. cu. 7, . 6r.25;,i,. zl6.:/'i s' At,:cr /.
Company Name • 16.INNER CA cGORTUBING(neotliermal&Tailed-loop) :. • • • • .
2.Well Construction Permit#:. " pc; . O(�3`p 8 . . . . .. EOM. TO• .' D R. . TffiCKNFS9' MATFRiAI
oS 3 — .it . .• .ft . '' m
List all applicable well conetniction penni.ts(i.e.County,State Variance,eta) , • " -
-.ft ft is .
3-Well Use(check well use): • •
• iZ sCla;i?Ely
Water Supply Well: ".•: . . ' FROM:• •TO DIAMETER SLOT SIZE ,THICKNESS• MATERIAL ' ,
❑Agricultural . " ❑ oipal/Publio . . it i°` . : . . :
. ❑Geothermal(Heating/Cooling,Su 1) li'Residential Water Su l•'sin ft ' ft in. .
PPY PPY•( g�)• �
Dlndustrial/Commcrgial, ' 1. . 'DResideatial Water Supply.
star : 18'GROUT ' . • . • ' - . : . • ..
•
( •. : FROM. : •TO •• 'MATERIAL • ` EMPLACEMENT METHOD&AMOUNT
Non Water Supply Welly _ • . " . _ -
0 , ft 20 ft Concrete GraVity,Flow
❑Monitoring ❑Recovery . . ' . . • •, ft
Injection Well: ; . f• t ft
❑Aquifer Recharge , •s • OGrounchvaterRemediation . 19.SAND/GRAVEL PACK Of applicable) • '
• • • • FROM•. TO • •. MATERIAL . EMPLACEMENT METHOD
❑Aquifer Storage,and Recovery ❑Salir�ity.l3alrier : 6
• . '❑Aquifer Test. ❑Stoanwater Drainage, . '
. • •❑Experimental Technology •
. : ❑Subsidence Control . " . • . ' ft ft .- •
7A- sheets ncc
. . OGeuthemial(ClesedLoop) -•.• OTraccr. FROM
DRILLING
TO
LOG.(attach Dadditional FStStiPTION(rotorifhardnea,sar9)roll oclt WO;ppindxe,rtt)
❑Geothetmal.(Heating/Coolin Retum) .00ther(explain under#21 Remarks). • "ft it • / . : . • . .
.4.Date Wells)Completed: . Z •Well IITH SS_fa 7( it • ' �c I?f:�i�".
•
Si.Well•Loration:. 7 ft 3�� ft i' [�-/r"G twJ l�.
j_r aLucI- 4Z, . . ft. ft.
•
' . FaeilityIOwneiName, , • FacilityD#(ifapplicable) • ' ' • ft. ft -, _ •' -- _�
x
()L Ari" It:� : •13lactf. f v\ T(1 • , .. ,ft ft • . : i•. • .
•
. a qp
Physical Address,City;and Zip' 21-REMARKS NO V 1 % .L 0 C 4.
•. . . . 6 6,564 6.5.6 .
County Parcel Identification No,(PIN) . D !4 J{.r
• • 'Sb-Latitude and Longitude in degrees/minutes/seconds or decimal degrees: • 1 ' :
(ifwell field one lallong is su$tment) 22-'Certdication:
. . Ciq
' 3°5-S• ✓‘).r7a.S /N•• � .ai)• 13 idtevR• tt w .•. . , /�.•// • . • 02_>,-AL_
" . - SigfficureofC ' edWell6Cobtrac•r
• 6.Is(are)the wells . ermanent. or .❑Te o • • •-" ' • " ' '�, •() � mP ��' . srgmng this"fomt,l hereby certify thatthe wells)was(were)isonsmrcted rn aceordmrce•'
. " with ISANCAC 02C'.0100 or 1SANCACO2C.0200 Well Construction Standards and that a.
7.Is this a repair to an existing well ❑Yes"or • tsfl o • • •copy of this record has been provided to theme!'owner. . . , . • ' • • '
, 'Ifthis is a repair,fill ottt known well construction information and erplam the white of the
. repairwsder#21 remarlasection or on the back of thisfonn. 23.Site diagram or additional"well`details: '• . •-
:: : the back of this to,provide additional well site we .
/ . . , ' :You may use page , tidetails or •ll.
8.Number'of wells constructed: • / •construction details.-You may also attach additional pages if necessary.
For multiple ityectian ornon-watersvppty wells ONLY with the smne construction,you can •
srrbrrct onefor»s S17BMITrAL'INSTUCTIONS . • •
9.•Total well depth below land•surface: • 3()5 '' • ' (ft.) .24a. For All Wells: Submit•this form within 30 days of completion of well .
_ For multiple-wells.list all•depths ifdifferant(example-3Q200'and2@100') .• construction to the following: .F . .
10.Static water level below top of casing: • Divisioa-of Water Quality,Information Processing Unit, .
If water level is above casing:use"+" 1617 Mail Service Center,Raleigh;NC 27699-1617
11.Borehole diameter:. .i. 4. (m.) . • 24b-k`or Injection Wells: In addition to sending the form to the address in 24a
fZOt$ry 'above,.also submit"a copy.of this'form within.30 days!of.completion of well.
12..Well construction method: - • 'construction to the follovaing: . • - .
(i.e.-auger,rotary;cable,direct pash,etc.) : - '
' Division of Water•Qnality;Underground Injection•Centrol Program,
FOR WATER SUPPLY WELLS ONLY:'. • . ' - - •• •• •. • . . •" 1636 Mail Service Center,Raleigh,NC 27699-1636. •
l3lOWln -RI 24c.For Water Suonly&Iniection.Wells: In addition'to sanding the,form to •
13a.Yield(gpin) ! '• Method of•test: g g the addresses) above, also submit tone copy of this form within 30 days of'
13b.Disinfection type::Chlorine.' • '•Amount: . "tl0•l_ , .oZ. , completion of well construction to the cou•nty health•department of,the county• •
• where.constructed, 1 i.
Form OW-1•:- - North carolinaDepartnient of EnVironment anti Natural.RcsoOrces—Diviiirm Of water Quality " Revised Jan.2013,