GW1--06866_Well Construction - GW1_20241115

.WELL,CONSTRUCTION RECORD . - For lnttmaluse ONLY: : • ' , , • . • .
This form can 6e used for single or mnl6ple wells
1.Well'Coata c1orlaformation:
•
• Bobb .W. Potts - • 14.WATERZONES . • . . ;.
Y . . . - . . . , ' FROM.- TO . , 'DFSCRWTION .
m
: .Will ContracterNae' . : . : .' • ft .R10:f . - -. 1- - -. .-.. .
fi ft ,_.
'
NC Well Con orCctufica1ionNuther 15.011TERCASJNG(for otnl6•casedwells)OR LINER(if ) • '
•
' FROM TO ".- DIAMETER I - THICKNESS . ' .MATERIAL. •
. Ferguson's Welland Pump;, L,LC • . • . : . . . , (`j..it: '.7 ft. at. '.'rt• &/t. 45, . pec5 j)A2i . .
• CompanyName • • • • 16.INNER CASIIvOR G.(taeodOettual elase8aoop).
. a ,
. ,1 ! FROM TO- -' DIAMETER THICKNESS' MATERIAL
• 2.Well-CoasQacHon Permit#: . .t�V.a UO.t( I • .ft ft • . . hr
List all applicable well cairhuction pendis(i.e.County,State,Variance etc) ft - .. ' •
: :3.Well Use(cheer well use)= • .. , - -.
E ply Wdl FROM: TO DIAMETER SLOT SSIZEE THTCENESS MATERIAL
ft ft is
cultural .. ❑ paliPublic
❑Geotheermal(Heating/CoolingSupply) pp y•( gl) • ' it' ft in . .
BResidential Water Su 1 sin e . ' , •
' • ❑lndusttial/Commeruial..:. °Residential Water Supply(shared) .: 18.GROAT!' ' • •: • • : ' • ' . , - • :- •
❑Iriigation PROM.'•. •TO '• . • 'MATERIAL EI wLACKMENTMErHOD a AMOUNT. ' • .
Non-WaterSupplyWdl: : .0• • C. 20 ft Concrete Gravity.Flow
[7Monitotiag ❑Recov ft: ft ,
ery
. •Injection Well: fa ft ;
❑Aquifer Recharge . : • • • • ❑GroundwaterRemediation•'*. • 19.SAND/GRAVEL PACK(dapplicable) • ' • • '
❑ 'I Storage and Recov FROM . TO MATERIAL F1s�LACEa� Th�tTiOD _
Atee ery ❑Salim Barrier :. •
'❑Aquifer Test- . . • ❑Stormwater Drainage •' ft ft .
' . •-OExperimental Technology ' . '❑Subsidence Control • ' . 2a DRILL=NG LOG.(atta h additional sheets ifnscessars) ' P
•❑Geutheimal(Closed Loop) ❑Tracer .• : ' .• '• PROM .• TO .- DESCR '►ON rotor,hardness,soIVrodt ty'ae.grain die,ere.) •
'❑Geothermal(Heating/Cooling/tetum) • ❑Other(explain.under'#l21 Remarks). . .'0� ,ft.• sv .',IL. ' •• 1.0��i • • • • • ,
. . ... .
�r 50 6s'.. " .S� .cp,
•
' 4.Date Wells)Completed: (/ 3�/.r2 y weII IB# � � . • -
Sa.Well Location: '
��rg4�tcc (knl,Jrn S.LLC: - . . ". -• . . .`7a` S • • . . •.
9 � it. ft •�
• Facility/Oiweiidamt. . • • . " ' • Facility1E4'(ifapplicable)•. • ' .0�_ --.
h l,1 AiC (:tom- a:d Le l•�.e4 j-ov ''aQf'71 g f.: . . . . -ft., . • • . - .-/; t
Physical Address,City and Zip•' �r 2L REMARKS NOV _ U Z�t
County Parcel ldentifioabonNo.(PIN) . : , • • 1.. ;:: • ;-�Y
' Sb.Latitude and Longitude in degrees/minuttes/seconds or decimal degrees•
(ifwell fieeld,one latllong is.sufficictit) 2 S• �.. 22.CertSdeation:-
• ?v-S '(0 '7/3 0Ci./N•g'21)3?• �1 -f t. w. ' .: .,, .y ;/
.• S gaanue /,of CcifiScd d1 Contractor . D
6.Is(are)the well(s)::E}Perman•ent' .. '.OTeLoporary. • . :By age thi •s Thereby eery.thaitthe wells)w•as(were)constructed;in accon'ance '
' •' • • '' ' ' with 15ANCAC 02C'.0100 or 15A'NCAC 02C.0200 Pre!!CoretnrctlorsStandardsand Mid a
7.Is this a repair te-an'existing•weelk• ❑Yes- or P1No• • . . •- copy oflhis record haa been provided to the well osmei.• ' . • • . . '
riles it a repair,,fill oft!known well construction nrjorinalion and explain the nature ofthe . •
• repair wider#21 remrks section or on the back,,of thisfeint. . 23.Site diagram or additional Well details
. • . . •. .' : you may use the back of this page;to.provide additional well site details or well : . ,•.
.• ' 8.Number of wells constructed :•I - ' . • construction details.:You may also attach additional pages if necessat}.
For-multiple 1 JecNaiornon-walersttpply wells ONLY,with the.same construction,you can . ' .
svbimt eraeforns SUBMITTAL INSTUC PIONS
9.Total well depth below land surface:
p �.� (ft.) 24a. For All'Wells: Submit this,form within 30 days of iompletion of well
. For multiple wells list all depths.rfdt erott.(e wnpk-3 a 200'and 2@100') construction to the following: ,
10.;Static water level below top of casing..• • 2•(9 . • • • • . "•(t) • • Division of Water'Quality,Information Processing Unit, . '
Ifwater level is above cirsing,are"4-" . ' '1617 Mail Service Center,Raleigh,NC 27699.1617 - . '
11.Borehole diameter..: .' • - • • - (in.) 24b.For Tnieetion Wells: In addition to sending'the Sinn to•tfie address in 24a
• • ••' • • • • •• • 'above, also:submit a.copy.of.this:form within_30 days of.completion of well •
: . • 12.Well construction method.' . -ry - construction to the following: : ' I' „ . • . . -
• (i.e.;auger rotary,cable direct push,.etc.). .
Division of Water Qaality,'Undl igrotmd Injection Control Program,
•. ' FOR WATER SUPPLY WELLS ONLY= •. • .1636 Mall Service Center,Raleigh,NC 27699-1636. - •
/' B lowi plowing-Rig • 24c.For Water Sum ily"&Iniectioli Wells:'In addition to sending the farm to • •
13a:Yield m Method of test: g •(SP ) (.C. • •• • the address(es):above, also:submit one:copy of this.form within.30'days of •
•Ch1orine.: •' • ' �J'2 completion of.Well Construction.'to.the',cou ty'health.department•of the county
13b.Disinfection type: • . Amount:' • •'/ it - oZ. •awhere constructed,. I .
:ForaCW=1,• •• North Carolina Department of Environmentead.NatnmlResom ucs-DivisionofWater.Quatity , ' Rcvisud Jan.2013. . . •.