GW1-2021-00151_Well Construction - GW1_20211213

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This term can be used for single or multiple wsiLs
1.Well Contractor Information:
14:WATER ZONES
Bobby W. Potts FROM TO DESCRip1TON
Well Contractor Na f` ,� C'�
Nam
NCWC 2028-A ft ft
NC Well Contractor Certification Number 15.OUTER CASING multi rased webs OR LINER a bie
FROM I TO DIAMETER IWCKNESS MATERIAL
Ferguson's Well and Pump, LLC ft U1
Company Name 16.INNER CASING ORTUBIN daeed-1
FROM TO DIAMETER THICKNESS MATERIAL
L Well Construction Permit#:7 02-1 — h 03!a I rt irk.
List all applicable well construction permits(r.e.Cowry, fate,Variance,etc.) .
ft. tt 1a
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM I To I DIAhCMER I SLOT SIZE I TEaCENM I MATERIAL
ft ft
❑Agricultural ❑ pal/Public
❑Geothermal(Heating/Cooling Supply) esidmtial Water Supply(single) n it
❑Industrial/Commercial ❑Residential Water Supply(shared) FR GROUT '
FROM TO MATFEtIAI. EAPLACEbII3vT METHOD A AMOUNT
❑ tion . 0 ft 20 ft Concrete Gravity-Flow
Non-Water Supply Well: ft tt
❑Monitoring ❑Recovery ft ft
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK e
FROM I TO MATERIAL FMPLACEM1VN T MEMOD
❑Aquifer Storage and Recovery ❑Salinity Barrier fir. ft
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control 20 DRILLING LOG attrach sddltittml sheets if
❑Gouthermal(Closed Loup) ❑Trat:n• FROM I TO DES(R1PITON taus bardn wurocit etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks ft- ft-]
it ft G!J L
4.Date Well(s)Completed:r�����Well ID# ft ft
O
52.Well Location: R ft t G
bntal ejot a & ft .- -
Facility/Owner Name —� Facility 1D4(if applicable) ft ft 4
17 Qu i Cu z L r1 :l 8 7-1 rt tt
Physical Address,City,and Zip 21.REMARKS
County Pateel ldenti cation No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(dwell field,one Iat/long is sufficient)
p / t! g� oJJ1.4t7I A a w
D Signanve of fed
6.Is(are)the well(s): erm wt or ❑Temporary By signing this form,1 hereby certify that the well(s)was(were)constructed in accordwee
with 15A NCAC 02C.0100 or IJA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or o copy of this record has been provided to the well owner
1f this is a repair,fall out bnmm well corabvetion infomsation and explain the nalm of the
repair under#21 rrnwrks section or on the back of thisfom 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 neoessary
For muldple injection or not-water supply wells O Y with the same emstruc iot,you can SUBMITTAL INSTUCTIONS
submit ore form
9.Total well depth below land surface: ntLi S (tt) 24a. For AIl Wells: Submit this';form within 30 days of completion of well
For nv&pk wells list all depths if di erort(example- @200'and 2@100') construction to the following:
10.Static water level below top of casing: �1, A) Division of Water Quality,Information Processing Unit,
If water level is above casing,use + 1617 Mail Service Center,Raleigb,NC 276994617
11.Borehole diameter. (in) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Rota above, also submit a copy of this form within 30 days of completion of well
1L Well construction method Rotary construction to the fullovAing:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 AM Service Cep�rater,Raleigh,NC 27699-1636
13a.Yield(gpm) Method•of teat: Blowing-Rig 24c.For Water Supnly&Inieclion Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection Chlorine Amount: oz, completion of well construction to the county health department of the county
typo where constructed.
...c am w,t—i Rrcnnmra-nivition of Water Oualitv Revised Jan.2013