GW1-2021-07944_Well Construction - GW1_20210809

WELL CONSTRUCTION RECORD For Interval Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
1a.wATER ZONES
Bobby W. Potts FROM I TO DFSCRUMON.
Well Contractor Name
NCWC 2028-A " ft.
NC Well Contractor Certification Number 11 OUTER CASING for mnttirxted*dig)OR LINER a bk
PROM TO MAMETER I THICKNESS MATERIAL
Ferguson's Well and Pump, LLC p rti in, 1714,IA5 f c /
Company Name 16.INNER G OR
TUEING closed
FROM TO DMULIT R THICKNESS MATERIAL
2.Well Construction Permit#: l.) B 0Q-I S ft � in.
List an applicable wen condrvetion pernuts e.Convoy,State,Vw*ince,etc.) fL ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM I TO DLlME M SLOT SIZE ITHIC[QSESS MATER141
ft ft m
❑Agricultural ❑Muw "/Public
.
MG-thermal.(Heating/Cooling Supply) _. est/dential Water Supply(single)
R
❑Iadustrial/Comme rcial ❑Residential Water Supply(shared) F GROUT
FROM TO MATERIAL E11fPLACF1uffiT17 METHOD&AMOUNT
01irigation 0 rc 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 FROM e
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. TO MATERIAL II1FLACEIVIEN'f METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control 9a DRILLING LOG at4dn additional sheets if
❑Geuthermai(Closed Luup) ❑Tracer FROM I TO DFSLItWnON color'barde solUtncle Mie,grain Me,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain wader 421 Remarks) J) ft' 70 tt
ft
a.Date wen(a)Completed: wen ma s- ft.saftft
Sa.well Location: rt M e
0 k AJ '�)C'r Li— ft ft
Facility/Owner Name Facility MN(if applicable) ft, ft
l�G 114 i Q� K. Arr 5 RII�LI') M QFS 7/1 & ft
Physical Address,Ci ,and Zip 21.REMARKS
�� nn.toi' V(fJ U7�79,��n
County Parcel Identification No.(PIN) ^•F, rocessEl3a] TA
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: 1 i1 V t ®�1,1�voCY10
(if well field,one lavlong is sufficient)
_UO3 S'/O t 316 N T%r�-- �7�/�/ a'
,_,�(/__ S tare of sea w�; p traitor ta
6.Is(are)the well(s): CftCl_ cnt or ❑Temporary By signing this faun,I hereby cer0 that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standard;and that a
7.Is this a repair to an existing well: ❑Yes or copy of Sus record has been provided to the well owner.
If this is a repair,fill out blown well conswction ir¢ornNOM and ezpAt n the nmve of die Site diagram or additional well dwetsils:
repair wader#21 rents section or on due back of dds form 23.
/ 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 rm Ihpk byeceian or non-water supply wells ONLY with die sane earstradian.your can SUBMITTAL INSTUCTIONS
subnrit one farm
9.Total well depth below land surface: (fL) 24a For An Wells: Submit this form Nvithin 30 days of completion of well
For multiple wet;list all depths if diff—t(mniple-3@200'and 2Q100') construction to the following:
10.Static water level below top of casing: ��/� (ft) Division of Water Quality,Information Processing Unit,
If water level is above caft,use"+" - 1617 Mail Service Center,Raleigb,NC 27699-1617
11.Borehole diameter.
0 (ID) 24b.For Iniection 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: constrtu:tion to the follovaing:
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Man Service Center,Raleigh,NC 27699-16M
13a.Yield m of tat: Blowing-Rig 24e.For Water Supply&Iniection Was: in addition to sending the form to
(gP ) Method the address(es) above, also submitl one copy of this form within 30 days of
13b.Disinfection Chlorine Amount completion of well construction to,�the county health department of the county
4Pe. OZ. where constructed.
n-.........-.,, irr. ;.,,moo t sort Norval Rnsnurees—Division of Water Ouality Revised Jan.2013