GW1-2021-00153_Well Construction - GW1_20211213

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts FROM N1w9 DESCRIPTION
Well Contractor Name R' f`
NCWC 2028-A it f`
NC Well Contractor Certification Number 15.OUTER CASING or maltl cased webs OR LINER a ble
FROM TO DIAMETER TffiCKNM MATERIAL
Ferguson's Well and Pump, LLC d f j$ 4,LS 1,S C
Company Name 1ti IIVNER cAsnvc OR c closed
FROM TO DIAMEM IMCKNFSS MATERIAL
2.wen Construction Permit#: o�Oa i - L �l AS ft it
ist L aff applicable well cons&wdon permits(i.e.County,State,Varfmneg e�— R ft
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO Mba"M SLOT SM TIIICIINFSS MATERIAL
ft ft. hL
❑G
❑Agricultural ❑ crpateublic
eothermal(Heating/Cooling Supply) e'Residential Water Supply(single) ft ft in.
OlndustriaUCommercial ❑Residential Water Supply(shared) "L GROUT
FROM TO MATERIAL El•eUCEMENTTiWMOD!AMOUNT
Oliriaation 0 ft 20 ft Concrete Gravity-Flow
Non-Water Supply Well: ft ft
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 1%SAPID/GRAVEL.PACK Of nivilicaMe)
FROM I TO I MATERIAL EMPLACEb1E1VT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier & ft
❑Aquifer Test ❑Stormwater Drainage fL ft
❑Experimental Technology ❑Subsidence Control 20.DRILLING LAG atrnadh additional sheer if
OGeuthtamal(CausedLuup) ❑Trager FROM I TO DFSe1ttMON color,Avda solurocle etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks n ft tau
O & it
4.Date Wel!(s)Completed:G ��Well II)M1 ft ft
L
Sa WellLocation: R It t t
i� ChmIC ft ft
Facility/Owner Name Facility IINI(if applicable)
its ai Lt cSl-ci a n ft
�—
Physical Address,City,and Zip 21.REMARES
.r►f YYFI bC
County Parcel Identi5eationNo.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
a " y A; I
3S t'Z 1f S30�i N �z "�/D�/. �'38 w
�{ signature ea well Contractor, I)a
6.Is(are)the well(s): Lli'Ci cut or ❑Temporary By signing ft form 1 hemby cer*that the well(s)was(were)constructed in accorobtce
with 15A NCAC 02C.0100 or 154 NCAC 02C.0200 Well Construction Stamlmds and that a
7.is this a repair to an existing well: ❑Yes or [diV0 copy of this record has been prmukd to the well owner
If this is a repafr,fill out brown well constuction infimmaliorn and explain the nature of the
repair under#21 ranarb section or on tee back of this form 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 necessary'.
For multiple injection or M.-.Xer supply wells oNl r with the same�rrtetiar you can SUBMITTAL 1NSTUCTIONS
subnW onefom
9.Total well depth below land surface: ylo s (fL) 24a. For All Wells: Submit this,form within 30 days of completion of well
For multiple wells list all depths tf&fferew(mmnple-3Q200'and 2®100') construction to the following:
10.static water level below top of easing: $Q (ft) Division of Water Quality,Information Processing Unit,
Nwater level is above easing,use"+" 1617 Mail Service Center,Raid&,NC 27699-1617
11.Borehole diameter. �_(in) above,
For Iniection 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
12.Well construction rmethod: Rotary construction to the following:
i
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Uederground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method arteat: Blowing-Rig 24c-For Water Supnly&Inieet' Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13h Disinfection Chlorine Amount: _ �p OZ. completion of well construction to the county health department of the county
type where constructed.
.. ,.._.. .._��,+__,.__n��__-...eC.............-..,-.,A 1Qoh, i P—m—-Mvisinn of Water Ouality Revised Jan.2013