GW1-2021-06882_Well Construction - GW1_20210430

WELL CONSTRUCTION RECORD
For Infernal Use ONLY: �
This form can be used for single or multiple wells k
1.Well Contractor Information:
Bobby W. Potts 14.WATERzoNss i
FROM TO I DESCRiPIION
Well Contractor Name ft 3 7 rt
NCWC 2028-A ft ft
NC Well Contractor Certification Number 15.OUTERCASING(for multicatad.wdls OR LINER rt ble
FROM TO DIAMETER:. THICKNESS MATE
Ferguson's Well and Pump, LLC n a c
Company Name 1G INNER G OR G. fi
DIAMETF1t
2.Well
Construction
Permit#: Z o 16 U , Z b 7 I I FROM it it m,TO THICKNESS MATERIAL
List all applicable we11 construction permits(t.e.County,State,Yuman A etc.)
fL ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT stag 'THletavFS3 MATERIAL
ft ft in
❑Agricultural ❑ paUPublic
❑Geothermal(Heating/Cooling Supply) (�Aesida Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1&GROUT
FROM TO MATERIAL EMPLACEMT METHOD tit AMOUNT
Non-Water Supply Well. 0 ft EN20 Concrete Gravity-Flow
te
❑Monitoring ❑Recovery ft ft
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK rif.mWitablel
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EAPI ACENUM14MMOD
ft ft
❑Aquifer Test ❑Stormwater Drainage
ft &
❑Experimental Technology ❑Subsidence Control
2 L DRILLING LOG.attach addiliuoal atieeha if
❑Geuthermal(Closed Loup) ❑Traeer FROM TO DFAL'RIMON color hardness,soiUrock die,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft S ft
i
S*s
4.Date Well O fts)Completed: ���Well lD# ft tt
Sa Well Location: ft-
- t
744rw!
r u elerr (rm 4 e- ft ft
Facility/Owner Naine Facility ID#(if applicable) _
ft ft
f3 D SiePttH Vi6t& iy2 �kneIPYSAna,'He 073 ft ft
Physical Address,City,and Zip 30
21.REMARKS
Hen erSbYl
County Parcel Identification No.(PIN) ;.
P;'^ E^�iI1 l'sZl$
1
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification;
(if well field,one lat/long is sufficient)
Si of fled ,d Contractor to
6.Is(art)the well(s): er'manent or ❑Temporary By,ngrdng this form,1 hereby certify that the well(s)was(were)consInxied in accordance
with 15A NCAC 02C.0100 or 15A NCAC'02C.0200!Pell Construction Stmndw.&and that a
7.Is this a repair to an existing well: Oyes or 2Ko copy of this record has been provided to the well owner.
If this is a repair,fall out biown well construction b1 ornration and explain the nature of the
repair under#21 ranks section or on the back of thisform 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 may also attach additional pages if necessary.
For multiple injection or run-water supply wells ONLY with the same cautrudion,you can
subadt one farm SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: S 00 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2@100') construction to the following:
10.Static water level below top of easing: t� 00 Division of Water Quality,Information Processing Unit,
If water level is above casing,use ,+,, 1617 Mail Service Center,Raleigh,NC 27699-1617
I '
11.Borehole diameter: (m.) 24b.For Ineection Wells: In addition to sending the form to the address in 24a
12 Well construction method: Rotary Rota above, also submit a copy of this form within 30 days of completion of well
construction to the fuIlOaing:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground lajection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cent Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Blowing—Rig 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copyiof this form within 30 days of
136 Disinfection type: Chlorine Amount: 0 OZ. completion of well construction to the col health department of the county
where constructed.
i
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water t2uality Revised Jan.2013