GW1--06869_Well Construction - GW1_20241115

•
WELL CONSTRUCTION RECORD
• This form can be used for single or multiple Wells' For Internal Use ONLY: . . , ,
1.WelI Contractor/► Information: '
Bobby'W. Potts 114.W TERZONES. r • DESCRIPTION .. -
• Well ContractorName : ft ft 1 1 -
NGWC 2028-A. if. ft I 1
,NC Well Contractor Certification Number . ' 15.OUTERCASING'(formnlffessedives)OR LINER Alm )
FROM TO. DI P.5ET1rR I THICKNESS MATERIAL•.
Ferguson's Well,and Pump; LLC . . . • 0 fL. k7' . .4;1,5" 2/6i[2'- p2GS4)
.:Comfy Name - : ' .. 16.INNER CASING ORTU13ING.(eedeherm21 elosed4ouo) • -
r FROM TO.-. DIAM5 rER. . THICKNESS . MATERIAL •
IWell ConstraetionPermit#: CIIDo • C.)O'n 3r ft ft V.,in. . .-
. List all applicable well construction panels(a County,State,Varriatce,etc.)
ft ft. in.
' • 3.Well Use(cheek well use): - 17.SCREEN• •. . .
• Water Supply Well: • - FROM' TO DIAMETER, SLOT SIZE 'TRC MESS MATERIAL
i>
. ❑Agricultural ❑ pal/Public ft ft <
❑Geothermal(Heating/Cooling Supply) .•- .-.tial Water Supply(single) . . ft " ft is : . `
❑Industrial/Commereial OResidential Water Su l (shared) 18.GROUT - .- -
PP Y( FROM. ' : TO MATERIAL "" FF1v1PLACEMENTMETHOD St AMOUNT -
• Dhripation
Non-water supply Weil: p . ft' 20 ft Concrete Gravity-Flow - .
❑Monitoring ❑Recovery • ft ft
Injection Well: . : "•
fa ft
❑Aquifer Recharge. .' .OGrocnrdwater•Remediation - 19.SAND/GRAVEL PACE Odapaksble)
FROM -TO
MATERIAL' EMPLACZVIENTMETHOD
• •❑Aquifer StorageandRevery ❑Salinity Baer - , '❑Aquifer Test ❑Stormwater Drainage
ft. • ft-
-' • OExperimental Technology ❑Subsidence Control • '" r
20.DRILLING LOG.(attach addttleaalabafsifnoessat�l .
❑Geuthtainal(Closed Loup) ❑Tracer- FROM,r To . -DESCRIPTION(color,b.rdness,roll rock type,palm die,etc.) .
OGeothermal(Heating/Cooling Rettan) •• ❑Other(explain under#21 Remarks) ft _50 ...ft.• ` ( a ( ' • • . -'
Date Well(s) o leted: - coo ft b O ft J `� G
4.D to C mp 7�/�/2, WellID#. did r J
i.Well location:. • . . . • • c / • 'W ! � /4 . .
'.1 rtt'� l�((\ ((�r+ • 0 ft 4D5ft (�7'r)/2e
Facd.i Owner Name. FacilitylI34(ifapplicable)•. ft ft .m �.;,4._"' / i
4 F •N h kidcor r�i Swann of� 0877A. • , ft: ' ft
NOV 1, ; (1�4
Physical Address,City„and Zip''. 2L REMARKS !. ..
a1.ncombe.. . • ' .d (o.88i;a: 1 5 3 • ir< <.; F -,, s 4.,.;,,
County ParcelIdenUSCationNo.(PIN). '
Sb.LatitadS and Longitude in degrees/minn'tes/se cons or decimal degrees: ;'.
(if well field,one latAong is sutiicient) 22.,Certification
.7..i1/2,...4iy.i._ .
• signature o,C • Well Con r '
" 6.Is(are)the ivell(s):: ermanent or ❑Temporary • : By signing This form,I hereby certify'th t the wells)was(were)corwructed in accordance
with 1SANCAC 02C.0100 or 15ANCAC 02C.0200 Well Consiruclion Standards and that a
7.Is this a'repair to an existitig.well:• DYes• or lZ1Yo - • copy of this record has beenpravickd to the well owner.
• ' If this Is a repair,fill out lomwn:Well construction eformahon and explain the native of the ,
repair wider#21 remarks section oron the back of thisfonn. • 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 mmay also attach additional pages if necessary. •
' Forirwlliple ligeatiros or non-water supply wells ONLY with the sane construction,You can ' .• ' .?"•
submit aneforna ' SUBMITTAL INSTUCTIONS .
9.Total well depth below land surface: (l (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths lfcfrjerent(exanple-3Q200 C.
and2®100') - . construction to the following:
10.E Static water level below top of casing: , . .. .. (ft) Division of Water Quality,'1Information Processing Unit, •
If water level;is above casing;use"+" 1617Mal Service Center,Raleigh,NC 27699-1617 •
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11.Borehole diameter. i 42 (M.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
Rota above, also submit a copy of this form within 30 days:of completion of well
12.Well Construuction method: ry construction to the follov.ing: •
(i.e.auger,'rotary,cable,direct push,etc.) -
• / Division of Water Quality;Underground Injectzotr Control Program,
FOR WATER SUPPLY WELLS ONLY: ` - . • 1636 Mail Service Center,Raleigh,NC 27699-1636
• BIow•ing;Rig , 24c For Water Swish Be Iniectionl Wells:'In addition to sending the form to
13a.Yield(gpm) Method of test: . the address(es) above, also submit lone copy of this form within.30 days of `
• •Chlorine Oz, completion of well'construction:to the county health department of the county
13b Disinfection type: Amount: ,,.where constructed.
Form OW 1 ' . : • North Carolina Depacunent of Environment and Natural Resources—Division of Water.Qaality •Revised Jan.2013• '
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