GW1-2021-05892_Well Construction - GW1_20211025

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES
Bobby W. Potts FROM TO I DESCRIPTION
Well Contractor Name O o it
NCWC 2028-A " ft
NC Well Contractor Certification Number 1&OUTERING mnitl•eased wells OR LAYER a bk
FROM I TO DIAMETER I IMCKN SS MATERIAL
Ferguson's Well and Pump, LLC 0fto rt ! /6/ S ,417tlC 2-
Company Name 16.INNER CASING OR G facotherinal dosed-1
PROM TO DIAMETER TMCENFSS MATERIAL
L Well Construction Permit#: ol oa l -h 6A 4 y ft. n m'
List all applicable well conshvelion pernrits rLe.Comsy,State,Variance,etc.)
ft ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT STLE THICKNESS MATERIAL
tt ft �
❑Agricultural ❑=si
ai/Public
❑Geothermal ea Coolie Supply) tial Water S sm ft ft
� � 8 P'P Y) uPP1Y(single)
❑Industrial/Commercial ❑Residential Water Supply(sham FROM GROUT
FROM TO MATERIAL Et4PLACEMENT METHOD&AMOUNT
❑Iris lion . 0 ft 20 ft Concrete Gravity-Flow
Non-Water Supply Well: ft ft
❑Monitoring ❑Recovery
Injection Well: ft it
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK fir apsibable)
FROM TO EbO N'r METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier g ft
❑Aquifer Test ❑Stormwater Drainage & ft
❑Experimental Technology ❑Subsidence Control 21L DRILLING LOG atCaeh additional sheets if
❑Geothermal(Closed Loup) ❑Tracer FROM I TO DESLREMON color haHness wiVtnclt etc
❑Geothermal(Iieatin oolin Rebzn) ❑Other(explain under 421 Remarks) 4 it it 0
t 9 it Q
4.Date Well(s)Completed: Well ID# it ft.
5a.Well Location: R ft 1a t
C se .4 A I P tSe C r,t tQM Nf]raa ft ft
Facility/Owner Name Facility IIJ#(if applicable) ft ft
t A rZagn 2oa g *7 3o & ft 1
Physical Address,City,and lip 21.REMARKS
aµ`� '4" 'a q(A SA-]-J112 �ssln9
County Parcel Identification No.(PIN) I(1IJIm3 R SecO
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Widdion:(ifwell field,one lat/long is sufficient)v0 N Sl'1� ° /, 7L Y38'f WS Con for Da
6.Is(are)the well(s): ermanent -or ❑Temporary By signing this fortrt I hereby off*that the well(s)was(were)cotstrvcted in accordorce
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standmrk and that a
7.Is this a repair to an existing well: Oyes or $14o copy of this record has been provided to the well owner.
If this is a repair,fill out brown well construction information and explain the rtahme of the 23.air under#21 remarks section or on the back of this form Yo Site diagram or additional well details:
rep
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 byection or not-water supply wells ONLF with the same cortstructian.You can SUBMITTAL INSTUCTIONS
submit oneform
9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if tU erent(exmnple:3Q200'and 2Q100') construction to the following:
10.Static water level below top of casing: Yd (fk) Division of Water Quality,Information Processing Unit,
If water level is above amvig use + 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Rotary construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Lhr`dergromid Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cent er,Raleigh,NC 27699-1636
13a Yield m Method of teat Blowing-Rig 24e.For Water Suonlv,&Injection Wells: In addition to sending the form to
(gP ) the address(es) above, also submits one copy of this form within 30 days of
136 Disinfection Chlorine ,,,�,mt, �� OZ. completion of well construction toi the county health department of the county
type where constructed
V-1,ra.rrc.,a ri—rrmnnt„f F.nvimmmnt and Natural Resources—Division of Watcr Quality Revised Jan.2013