GW1--06862_Well Construction - GW1_20241115

/'WELL CONSTRUCTION RECORD . For Internal Use ONLY: : .
This forth can be used for single or multiple wells . .•- ,
• .I,Well Contractor Information: .
y� 14,WATER ZONES_ •• 1
Bobby W. POLLS, . PROM. • .TO . r -DESCRIPTION . • . . ' '
- ..Well Contractor Nnme • . ' R :j 4,y:ff. : I ,1 • • : -
• NCWC 2028-A . • . -:ft' 5io ft I .1: . . ' . . .
NC Well Con rCcitficatson Number . ' ' . '. . ,1S.OUTER CASING(formnlhrssed Wells)ORYJNER(i hie) - ,•
FROM TO . DIAMETER ! TRIMNESS , MATERIAL'.
Ferguson's Well and Pump,LLC . C-.fr.. '-(A 1 31' •1e''Z.1f1 IAA• " atcs 0 (e)
.' `Company Name . . ' 16.INNER CASING ORTl G'(slealbermal clotted-Zooli)
^! Lf FROM• . TO.. 'DIAMETER. . ;THICKNESS... MATERIAL . . . - ,
2..Well'Construction Permit# ' goo c- - O-(i iS .. , ft.. ft. '' m, .• ' . .
List al!applicable well ccmrbvction permits(r.e.Cotmty,St , ariance,•ele.) '. •
ale'V ft ' . ft is
•-3.Well Use(check well use): . ' • .
17.5CREEN =
Water Supply.Well: • FROM TO. . DIAMETER : SLOT SIZE .THICKNESS .MATERIAL
❑Agricultural. ' . ❑ ipaUPublic it ft •m •
OGeothermal(Heatmg/Cooling Supply) .t esidential Water Supply(single), ' ' ft • . . . ft•• • m., • • .
❑IndutriaUCommercial ' ❑ esidential Water SupnlY.(sliarerT) 18.GROUT - . • • ' . •
. .
Olmgation' - C
FROM TO 'MATERIAL EteLACENII+NTMETHOD&'AMOUNT .
Nth-Water SliPPl3'Wdl:...• ,
t? ft 26', , fc onbrete Gravity-Flow
❑Monitoring ❑Recovery fc, ft .
_Injection Well; • ft, ' . ft . ' ..
.❑Aquifer Recharge..,. : ' 0 Groundwater Rernediation .'' ' ' .19:SAND/GRAVEL PACK fti an icaie) ' . ,'
. . .❑Aquifer Storage and Recovery _ ❑Salinity Bamer : ' , .'. -7L' ' ,' . .
• FROM•' TO 'MA -EMPLACEMENTMETHOD'.
•
ft' . . .:ft. ..
. OAquiferTest . OStomiwater.Drainage - " • .
• . OExperimental Technology • . • OSubsidence Control fr ft ' ' . . A.
20.DRILLING.LOG.(attaeh adtYltioual sheets ifnee ssu9) . . .
•QGcutheamai(Closed Loop) l7Traixx . ' ' FROM - TO •• ' DE.SCWPIION(eetar,hardness,soil retic type,gtnin she,eta)
❑Geothermal(Heatuig/Cooling Return) OOthet(explain under#21 Remarks) J
., •.Q, ft ���,'.ft. Cl.Q. .'
ft /-
4:Date Wells)Completed: cal/JYWellIB# • • 70 fG �'S • Sit!.v )�J?
S'
C'� c
' ' oa.WeliLocatiou: '• . . �.
'Ste`: R� r
• q),.ft 6 d it . .., . ..
6( tUSCt,n.'1r V r-LChkb '. . ' . .ft. . ft:. r . .
•'Facility%Owner Name - `, ' • Facility ID#(if applicable) , ' ' '
ay ,
Physical Addrrss;City;and Zig. :
.'Nnu. 1 .i. ' c201
..y,/��}y y/y. G 2LREMARKS'
County - •' , Parcel Identification No.(PIN) • , . Ut f t C;r''.OG - '
Sb.Latitude and Longitude in degiies/mintiteslseconds or decimal degrees: • • I ' '
(if well field,one lat/fong is su dent] 22 Certification:.
7).5 .c(� �3.7, . N ; - IsSr� • W . . .. z
SignatureofC • Well,Contractor Dto
rctheel(s:'�P/ran r ❑Tp '6,Is(a ) .w ) emeat' ,o • emorary .• • '
By signing gins form,I hereby certify that.the wells)was(were)roru4rircted iri accoidmrce
• ' with1SA'NCACO2C...9100orISANCACO2C.0200 Well ConstrictonStandards and that a
• 7.Is this .is a repair to existing Well: ' ❑Yes .or ' i Nu ' - 'copy of this record hat been proviohd to the well owner. • . ' . . . . ' .-
.(fthis is a repair,fill out linown well construction otforinalion and exploin,the nature of fire. =
repair wider#21'renw/cssection or on`the bark ofthtsform. diagram Or Site'diagra or additional.weil details: • '
'• • You may use the back of this page to provide additional well site details or well ' '
8.'Number of wells constructed: • • /J construction details.'You may also attach additional pages if necessary
For multiple hp'ectlon or non waiter supply wells ONLY with the same coiutririz ion,you can .
i.
sub»uI aerefoirs. SUBMPITAL)NSTUCTIONS .
9 Total well depth below land surface: • 24a. For All Wells: Submit this form within 30 days'of completion of well
Formrrhiple wells list all depths fdrfferemit,(example-' 2Q.S ma) •
00:and2@I00') construction to the following: ' " :i . ,
' ' 10.Static water level below top of casing: •• (S). ' :1 (#t) ' . Division of Water Quality,:Information Processing Unit, . : •
• Ifwater level is above casing;rise"+" • ' •• ' • 1'617 Marl•Service Center,Raleigh,NC 27699-1617 ; '
p� 1
•
11:Borehole diameter: :i._ (fir.)•. 24b. For Tniectiori Wells: In addition;to,sending tie form toYhe address in 24a
RO- . above,.also-submit a copy of this form within 30.days of completion of well
' 12.Wellteonstruction method: ry '• . . construction to the following: .. ' .• .- •
(i e,auger,rotary cablq direct push,etc.)• .
• ,' ' . ' . • . ' •�' • . ' ' Division of Water Quality,Undergreimd injection Control Pengrani,
FOR WATER SUPPLY WELLS ONLY: • • 1636 Mail Service Center,Raleigh,NC 27699-1'636 . ' . '
'�
10• Blowin -RI ' . 24c.For Water Sunray&Iniectition Wells:"In addition tosending the fomi'to •13a:Yield•(gpns) � � ]kieiltod•of feat: g' . g � '
: 'the,address(es),above, also submit one copy. of this„form within.30 days.of ,
. Chlorine 50 oz. completion of well construction'to•the!county health.department of the county' -
•13b.1)isiufectioa type: Amount: ,where constructed
:Form CW-1 ' North Carolina.Department of Environment and Natural Resource's—Division of Water 9nalitY. . Revised Tan.2013 ' •