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Home My WebLink AboutGW1--06863_Well Construction - GW1_20241115 • 1 •. . . . . . . . . WELL CONSTRUCTION RECORD' For Internal Use ONLY . . . . . -•, - - • • • . • , : , „ • • This form can be used for single or multiple'wells ., , • .•' . • - •..• . . • ' . . - • • • - . . • - . . . . . . • . . . .• . • . ' • - - 1.Well Contractor Information: . • ' • • ' . . " " • . . . .. Boblpy W. Potts . • 14.WA'fERIONES,••• . FROM TO . . ,. DFSCRIFTION • , . •Well Contractor Name ft' (A,0 ft . I • •-, NCWC 2028-A ft. i(..c.4.2 ft. , I . . . . NC Well ContractorCcrtificadon Number . •15.OUTER CASING(for Mani-cased Wells)OR LINER(if a ) . FROM TO . . DIAMETER TFIICENESS • MATERIAL. • , Ferguson's Well and Pump, LLC • • • 0 ft*: S . ". 4 r.a V.in' t "Yq. - $7tee.,1 . . • - • . . . Company Name •• 16.INNER CASING OR TUBING(aeirdiernial dined-loop)' , • : FROM TO• -. 1'DIAMETER,: :TERCKNESS. . MATERIAL 2.Well Construction Permit#: o,Q(4_ _- 6 605-0 O . • .ft :. ft . . . •Liston applicable well conOtruction permits(La.County,Stale,Vordance,etc.) ft. • . . • • 3.Well.Use(r.heck well use): , • • • - • Water Supply Well: . .• . • FROM.• TO. :• DIAMETER SLOT srzE .THICKNESS MATERIAL .' . •' . . . • ClAgrimiltural 1:liclisa.1/Public OGeothermal,(Heating/Cooling Supply) rrfesidential Water Supply(single) ft -.. Olndustrial/COmmercial °Residential Water Supply(shared) 18.GROUT . • . • . • • . • ._ • ' FROM, 'TO .• ' MATERIAL ' EA:PLACEMENT MET1i0D St AMOUNT . . . °Irrigation .•: - .•. . .Non-Water 0 ft- 20 , . ft' Concrete•'. .. •Gravity-Flow : .."• . : . .. •• :'' l. . .. Supply Well: • . fr. • EIMOrlitOrifig. ' . °Recovery •Injection Well: - fr. ft .. ' . . . • . " . - . . °Aquifer kecliargc• 0 Grotindwater Remediation 19.SAND/GRA VEL PACTsf applicable) • . . • : • .. •. : . . '' : . ..', * LACEMENT METHOD•. . • •. •EMP • .' '.' °Aquifer Storage and Recovery I:Salinity Barrier . FROM TO maxima,ft. ElAquifer Test 0 Stotmwater Drainage ft. ft. • ' . • . '• • -• - 0Experimental Technology OSubsidence Control - • , • •..,, - t: •20.DRILLING LOG(attacb additional skids ffnecesitary) •:• •.-'• . •• •-.•'. • •. - 0 Geothennal(Closed Loup) • .OTracer . FROM TO . .DESLRIPTION(color,hardness,stare&tyveolrata si2e,et0 ..' .:. OCreothcrmal(Heating/Cooling Return) • 00ther(explain under#21 Remarks) 0 ft /0 .'ft.. ' '. • C'fay. .'b i0;610,1E_; -1 1Th i 5r-N U::I le- , e• • . . • ;55a0 ft. ••5. 0•• • ..•• : . '6 ii,,,teirra-i.fi•• •.•.•.x•• -•r.•••:-.. . ••,• ... • ••: 4 Date Well(S)Completed 2WlD# f s.81//(152040 - . :ft1 / : : . 5a.WeE Location: 3 : '. . A ft t . .•• -. ••. :., ••••..• • • • -•Facility/6=er Name. . . Facility tD#(if applicable)• • ft. ft . , . *" " q•-•-•e,..,,,• . Fn6 •:01A &ic A.(3 u...i Lc(ce.Nite Ericte . . ft. ft . . .' - " . . kft)V..I' .,... :2024. . ., . . ..'.... Physical Address,City,and Zip • .- 2L REMARKS. ' • . . ---Bu.n ro rft b.e qi 0 ?) 13" /g. . • „.....,....,...:••!: ,-,..___.....„,,,., :i !..,,,„ County Parcel Identification No.(PIN) • • • . . . . . ' . . . . Sh.Latitude and Longitude in degrees/minutes/Seconds or decimal degrees: 22.c e...„ , .0 : . • • . . . . . , . . . . . . . (ifwell field,one latflong is sufficient) 0 . . • , . . . •. . .• • 3SC Va 1-3 Z 3 croi- N 3'2` N 2•'•,1 ST ri.°1 w I' • , ./. • . •-.51.2,r/lx•Y . . frac . • . • . : . 6.Is(are)the well(s): 2fIgrmanent or .OTemporary • By signing this formi hereby cer-10.thai the well(s)was(were)constructed in aceordance • with 15A NCAC 02C.0100 or 15A'NCAC 02C.0200 Well-Construction Standards and that a :• 7.Is this a repair to an existing-well: OYes • or BIC • copy of this record has been provided to thewellowner- If tiris is a repair,fill out known well construction infortitation and explain the nature of the . . . , repair wider#2I remarks section or on the back of this fomr. 23.Site diagram or additional well detailsi . . 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 necessary. . . • . . For multiple hyection or non-water supply wells ONLY with the same construction,you cow submit one farm • SUBMITTAL INSTUCTIONS • ' 9.Total well depth below land surface: /q...S. (ft.) 24a. For All Wells: Submit this fOrm.Within 30 days of completion of well For multiple wells list all depths ildifferent(example--3@.200'and 2(,100) construction to the follovdng: 10.Static water level below top Uf(=shag: / .. (ft.) Division of Water Quality,:InformatithiProcessing Unit, If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617 1 , 11.Borehole diameter:- i ,.... 62 (in.) 24b.For Infection WeRe: In additiOn t.o sending the form to the address in 24a above, also submit a.dopy of this.fenn within 30 days of completion of well ' . • . r . 12.Well-construction method: •RotarY • construction to theftilloV.ing; .. ;• . (i.e.auger,rotary,'cable,direct push,etc.) Division of Water Quality,lindergriomd Injection Central Program, FOR WATER SUPPLY WELLS ONLY: • 1636 Mail Service Center,Raleigh,NC 27699-1636 • 13a.Yield(gpm) )0 Method-of test:.Blowing-Rig 24e.For Water Swink&Inieetion Wells: In addition to sending the foma to the address(es) above, also submit one copy of this form within 30 days of. • .• . 13b.Disinfection type: Chlorine . nut:- . R 0 oz. : completion of well construction to the county health departrrient of the county • „where constructed. - . • Form GW-1 . North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jae.2013 •