GW1-2021-00155_Well Construction - GW1_20211213

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This fi)m can be used for single or multiple wells
1.Well Contractor luformation:
14:WATER 2ANF8 i
Bobby W. Potts FROM TO I DESCPJMON
Well Contractor Name n n
NCWC 2028-A ft. rt
NC Well Contractor Certification Number 15.OU'fM CASING steed wells)OR LtDIIER
FROM TO DIAMETER THICKNESS I MATFRL41,
Ferguson's Well and Pump, LLC 0 n wIVAIA.57 1,Avc -22,all
Company Name 16 INM CAMG OR G dried
FROM TO I DIAhLlER I TBX30M S TER AL
L Well construction permit 0: o`W I — b D a 35- n rti in.
List all applicable welt eonsom ion pemats(ie.County,Slate,Yarlmree,etc.) n ft is
3.Wen Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMErM SLOT SIZE TffiCKNESSS MATERIAL
ft ft �
❑Agneultutal ❑�esideelntiml
lie
❑Geothermal(Heating.Cooling Supply) ter Supply(single) ft ft
.GROUT
❑Industrial/Commercial ❑Residential Water Supply(shared) 18
FROM TO MATERIAL EMPLACEMENTMETHODaAMOUNT
01nigation , 0 n 20 ft Concrete Gravity-Flow
Non-Water Supply Wcl: ft ft
❑Monitoring ❑Recovery
Injection wen: n ft
❑Aquifer Recharge ❑Grotmdwater Remediation 19.SAPID!(TtAVEL PACK e
FROM TO I MATERIAL I Emn.ACEMZNT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier n n
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control X I1PJLLING LOG attach add dmA drceta N
Mouthermal(Clusetl Luop) ❑Traua' FROM I TO DESCRIP'1'[ON color hardnem wWre&OW,01M 121 etc
❑Geothermal(Hca' oolin Return ❑Other(explain under#21 Remarks n U ft.
C D ft. ft.4.Date Well(s)Completed: Well IDk n n
5a.Well Location: n n r
��f1�i 11a N A n n ft
Facility/Owner Name Facility ID#(if applicable) ft ft
iM l ue(rK r24pad- N IPlr 90/5 n ft
Physical Address,City,and lip 21,REMARrta
I Arllt'l')IOP
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in d ates/seconds or decimal d
� n ems' 22.Certification:
(if well field,one lat/long is sufficient)
-947�wwm of fled Well Contractor le
6.Is(are)the wells): QPe ent or ❑Temporary By sigma rids fmm,1 h—by certify that the wieA(s)was(were)cop Onrc00 in aeaon mrce
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Stardmris and that a
7.Is this a repair to an existing wen: ❑Yes or HNo copy of dds record has been provided to the well owner.
Ifd ds is a rep*fill out known well amrtruetiwt b#amat on and explaw the Sauce ofthe
repair render#21 nemarks section or on doe back of tsform. 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 wens constructed: I construction details. You may also attach additional pages if news q.
For multiple h#ecao n or non-wmer supply wells ONLY with the same canstraeikom you can SUBTMAL INSTUCTIONS
subnW oneform 2
9.Total well depth below land surface. l^ (fL) 24a. For Alt Wells: Submit this form within 30 days of completion of well
Fornmdaple wells list all depths if&ffv t(--pie .3&00nn'and 2@100') construction to the following:
10.Static water level below top of casing: d�� (ft) Division of Water Qnanty,Information Processiug Unit,
If water level is above cafe,use"+" 1617 Man Service Curter,Raleigh,NC 2769!M617
11.Borehole diameter. !� (m.) 24b.For Iniecti 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
It Well eonstanetion method: Rotary wnsttuction 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 C urter,Raleigh,NC 27699-1636
13a.Yield(gpm) 15 Methodpf teat: Blowing-Rig 24e.For water Sauuly&Injection Welk In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
Chlorine F O OZ. completion of well construction to!the county health department of the county
13b.Disinfection type: AmountF where oonsir»oted
-e ...A v-,,,.sl R.c.nm•:c_Nvicinn of Water nudity Revised Jan.2013