GW1-2021-05901_Well Construction - GW1_20211025

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor I�nFformation:
Bobby W. Potts 14.WATER ZONES
FROM DESCRIPITON
Well Contractor Name ft 3 i1V ft
NCWC 2028-A ft ft j
NC Well Conttactor Certification Number I&OUTER CASING ami6 aed;�te0a ORLiNER d
.FROM TO DLIMETFR Tfi[QdVESS MATERIAL
Ferguson's Well and Pump, LLC f` 150 ft 16 r UP, I A/C L
Company Name 16..EgNER CASING ORTUBIl.G: dumd
/ FROM TO DIAMETER THICKNEM MATERIAL
2.Well Construction Permit#: 1.9 7-7 ft_ ft in
List all applicable well covuhuction permits(i.e.Couiibi•'Stale,Variance,etc.)
' ft `ft m.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER I SLOT s= I imcK m I MATERuL
ft ft in.
❑Agricultural ❑ blic
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) h• ft in.1
❑Industtial/Cornmercial ❑Residential Water Supply(shared) 11L GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri ation 0 IL
Non-Water Supply Well: 20 f' Concrete Gravity-Flow
❑Monitoring ❑Recovery ft. ft
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19..SAND/GRAVIRL PA Vamlicsilallel
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL EMPLACEdlENTIIW MOD
ft. ft
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control
2k DR1I.l ING LOG.attar additional sheets tf
❑Gcutheamal(Closed Luup) ❑Tracer FROM TO DESCRIPITON color,hardnes,sWUroclt etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) I ft /100 ft %
OV
ft. ft l
4.Date Well(s)Completed: 1 Well ID# R 0 ft
Sa.Well Location: Ardlerl-
Id R Zlt) ft ,
nhel� .l�t(�t sit'jiL��Z ft. &
Facili Owner Name Facility ID#(if applicable) ft ft
3L6 5 Yphn S lf?CUC/ Qaa d /Otl d(j2&< ft ft
Physical Address,City,and Zip
21.REMARKS
�--�
l a/CC U
County Parcel Mentification No.(PIN) 1m3t10n On
Ser
5b.Latitude and Longitude in degnees/ndnutes/seconds or decimal degrees: 22.Certifitstion
(if well field,one laillong is sufficient) •
r '
�S�S_2 G,BD4 N _ �`I°Cl�Ozo,<1672 w -6,11A,
Sigffitrrre of ed Well Contras r to
6.Is(rut)the well(s): er nranent or OTemporary gy ri�„g fa„R 'I -&�y that the well(s)was(were)cwarducted in accordance
with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construcam Standmds and that a
7.h this a repair to an existing well: ❑Yes or BPTo copy of dus record has been pmvi&d to die well owner:
If this is a repair,f ll out brown well construction b¢onnation and explain the nature of the
repair under#21 rrmmiis section or on the bark of this fomc 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 multiple hyection or non-water supply wells ONLY with the same eansbudion you can
submit one form SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 330 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depdu if drfferrnt(exmnple-3@200'and 2@100) construction to the folloN*:
10.Static water level below top of casing: y0 (fL) Division of Water Quality,Information Processing Unit,
lfwater level is above casing,use"+" 1617 Matz Service Center,Raleigh,NC 27699-1617
11.Borehole diameter 1 (m.) 24b.For Inieetton Wells: In addition to sending the form to the address in 24a
Rotary above, also submit a copy of this form within 30 days of coil
etion of well
12.Well construction method: construction to the fulluvaing:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-16M
13a.Yield m -Blowing-Rig- 24c.For Water Summly&Iniection Wells: In addition to sending the form to
(gp ) ��_ Method of test: �g
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chlorine 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