GW1-2021-07784_Well Construction - GW1_20210809

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14,WATER ZONES P
Bobby W. Potts FROM TO DESCRIPTION
Well Contractor Name ft
NCWC 2028-A ft. ft
NC Well ContractorCertificalionNumber 15.OUTER CASING ermal4-c ted.t4ena OR LINER if 6le
FROM I TO I THICKNESS MATERIAL
Ferguson's Well and Pump, LLC r
Company Name 16.INNER CASING OR TIJBU. d."
-7-/q� 7 PROM TO DIAMETER MCKNM MATERIAL
2.Well Construction Permit#: ft- ft. In.
List all applicable well construction perndts(Le.County,Stage,Parbice,etc.) fL ft
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIANWrE t SLOT SIZE THICKNESS MATERIAL
ft ft in
❑Agricultural ❑ ctpaUPubhc
❑Geothermal(Heating/Cooling Supply) esidenttal Water Supply(single) H• ft hL
❑lndustrial/Cominercial ❑Residential Water Supply(shared) 1&.GROUT
FROM I TO MATERIAL Et]LACEM NT METHOD&AMOUNT
❑Irri ation 0 ft 20 ft Concrete Gravity-Flow
Non-Water Supply Well: ft ft
❑Monitoring ❑Recovery
ft ft
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL'PACK. e
FROM TO I MATERIAL I EMPLACEMENTAMMOD
❑Aquifer Storage and Recovery ❑Salmiry Barrier & ft
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control DRILLING LOG adtitioaal Amis if
❑Geothermal(Cluscd Luup) ❑Traccr FROM TO DFS(.TUPTION wW hardn soNrocQ d2e,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) I a ft /S ft a[
ft. 2 D It.
4.Date Well(s)Completed: Well ID# L'1 R 2 R
5a.Well Location: 2-7
ft ft r t
Fac�ilityy/OO�wner Name Facility W4(if applicable)
'216 ��n ?�"rW I-LtI2P Y�ix�� t_� ft ft
Physical Address,C4,,tand Zip y�� 11,REMARKS
q /-7 0 7 ' 0 &Z8, �rnr..SS1Ca3 til
County - Parcel Identification No.(PIN) In 'J%r' t:"' csp-doin
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Ce on:
(if well field,one lat/long is sutiicieat) _
3 ° 1w, � 24 5/421),9/Y/ 1 4- tfll4v
w
� Signature of Q&ficd Well Contractor
6.ly(are)the well(s): 211'ermanent or ❑Temporary By signing this Earn;Thereby certify that the well(s)was(werie)constructed in accordmrce
with ISA NCAC 02C.0100 or 15ANCAC 02C.0200 WeR Coitslruetim Standards and that a
7.Is this a repair to an existing well: ❑Yes or (d1Ho copy of this record has been provided to the well owner.
If this is a repatr,fill out known well construction irrfonnation and eipla in the nature ofthe
repair under 921 remarks section or on die bank of#=form 23.Site diagram or additional well Aetails:
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 i,yeohon or non-water supply wells ONLY with the same eanabrkdion you can
submit oneforna SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 30J qL) 24a. For An Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tf dtjjerent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of cooing: �
Q (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Man Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in) 24b.For Infection 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 completion of well
12.Well construction method ry construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Curter,Raleigh,NC 27699-1636
13a.Yield(gpm) 3 Method of test: Blowing-Rig 24c.For Water So i &Injection!Wells: in addition to sending the form to
the address(es) abc ve, also submit lone 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- ivision of Water Quality Revised Jan.2013