GW1-2021-01776_Well Construction - GW1_20210430

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
Bobby W. Potts It WATER ZONES
FROM TO DESCRDr1TON
Well Contractor Name ft 2111d, n
NCWC 2028-A h ft
NC Well Contractor Certification Number I.S.OUTER CASING forr wed yells OR LINER d ble
FROM TO DIAMETER THICENISS I MATERIAL.
Ferguson's Well and Pump, LLC $ h 2 S 2
Company Name 16.INNER CASIIIIG OR TUBING; dosed
/� ` � FROM TO DIAMEIPZt THiCKIVPSS MATERIAL
2 Well1 Construction Permit#: IH� �11 /,I .t/A n ft itr.
List all applicable well conshvchon perndts(Le.Cotorry,Stare,Yarimice,etc.)
n ft �.
3.Well Use(check well use): 17.SCREEN
W!!spftpply Well: FROM TO DIAMETER SLOT SIZE TIUCKNESS MATERIAL
OAgrift cultural ❑MunicipaUPublic ft in.�
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) n it is
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT
[]Irrigation
FROM TO MATERIAL EMPLAC M NT METHOD if AMOUNT
Non-Water Supply well: 0 ft 20 ft- Concrete Gravity-Flow
❑Monitoring ❑Recovery ft ft
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation it SAND/GRAVEL PACK e
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL DeLACEMENT11lMOD
ft ft
❑Aquifer Test ❑Stomtwater Drainage
❑Experimental Technology ❑Subsidence Control ft ft
20.DRILLffiG LOG:atbich additional Amok ffammaW
❑Geothermal(Closed Loup) ❑Tracer FROM TO DFBCRIFTtON cdor hardn sdurodr do
❑Geothermal(HeatingCooling Return) ❑Other(explain under#21 Remarks) ft tt
4.Date Well(s)Completed:J Well 1D# n ft
/ C
Sa./Well Location: r h S+ ft
ft ft
Facility/Owner Name Facility ID#(if applicable) h h
3qd UDo_(r Wh;kr bra It t2� rr,A�sh t II .2AI h n r;� Re
Physical Address ity,and Zip -
' 21.REMARKS
arty Parcel Identification No.(PIN) Ai R A
WLULI
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees;
(if well field,one lat/long is sufficient) 22 Certification:
/
57°�l 312, 1/ N 2 /.7�� W9 4 MIL-24 5117A?
,
Signature f ed Well Con for
6.Is(are)the well(s): C+7Permanent or ❑Temporary By m'g-'W this fasrt;I hereby-POY that the we (s)was(were)constructed m acconimrce
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Stmrdards and that a
7.Is this a repair to an c3 isting well: ❑Yes or 131Ro copy of this record has been pmvic ed to the well owner.
If this is a repair,full out known well combustion h formation and esplatn the nanoe of the
repair corder#21 remarYs section or on the back of dzisform 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: ( construction details. You may also attach additional pages if necessary.
For n uUiple b#action or not-water supply wells ONLY with the same conslrachon,you can
submit one form // SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: Btu- (g,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells/at all depths if different(cmiple-3@200'and 2@100D construction to the following:
10.Static water level below top of casing: Z0 00 Division of Water Quality,Information Processing Unit,
Ifwater level is above casing,use"+- 1617 Marl Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. W 0-) 24b.For Injection Wens: In addition to sending the form to the address in 24a
Rotary above, also submit a copy of this form within 30 days of completion of well
11 Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground bajecdon Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Marl Service Cen i ter,Raleigh,NC 27699-1636
13a.Yield(gpm) 30 Method of test: Blowing-Rig 24e.For Water Supply&Inaction Wells: >n addition to sending the form to
the address(es) above, also submit one copy''of this form within 30 days of
13b.Disinfection type: Chlonne Amount: OZ, completion of well construction to the county' health department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013