GW1-2021-00157_Well Construction - GW1_20211213

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
i
1.Well Contractor Information:
14.WATER ZONES I
Bobby W. Potts FROM TO DESCRIPTION
Well Contractor Name ft' ft'
NCWC 2028-A & & i
-NC Well Contractor Certification Number 15 OUTER CASING mald-cosed well) OR L]NER a ble
FROM TO DIAMETER TERM, SS MATERIAL
Ferguson's Well and Pump, LLC 1 hL194,4A S Z
Company Name I&INNER CASING OR TUBING faeodwroud closed
FROM TO DIAI�IER TMCSNM MATERIAL
2.well construction permit N. �I S / - 60�(� ft. ft
List all applicable well construction pernrits(ce.County,State,Yarlawc etc.)
tL ft im
3.Well Use(check well use): 17,SCREEN
Water Supply Well: FROM I TO I DIAMETER. SLOT SIZE TIRCIM SS I MATUUAL
ft ft in,
.
❑Agricultural ❑Munic tic
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft
❑Indus&ial/Commercial ❑Residential Water Supply(sharer) 1&GROUT '
FROM TO MATERIAL McLACElNUM MEMOD&AMOUNT
bins lion 0 20 ft Concrete Gravity-Flow
Non-Water Supply Well:
[t ft.
❑Monitoring ❑Recovery
Injection wen: n ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRtAVEL PACK ff Wficable)
FROM TO I MATERIAL EMPLACEI�ffit7T11�1HOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft, fe
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Tecbnologv ❑Subsidence Control X DRILLING LOG attadr additional sheets if
❑Geothermal(Closed Loup) ❑Tracer FROM I TO DFSCRIYIIUN odor bade soturock d2e,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks ft ft
7 ft ft
4.Date Well(s)Completed: Well MN ft ft
See.Well Location: ft ft
`SAAac #A// ft97F ft
Facility/Owner Name Facility MN(if applicable) ft ft 3 2
1h red Llrl4 & ;c jr�ainuk A) 0 eyo ft. ft
�+rn—
Physical Address,City,and Zip 21.REMARKS
County Parcel IdentiticationNo.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
S o3 N '.2- 20 t 0 V W �:bA& IAIII
sigmnue of eel Well contractor nee
6.Is(are)the well(s): ermanatt or ❑Temporary By siptfrtg this form,I hereby cer*that the wefl(s)was(were)constructed in accomlance
j with 15A NCAC 02C.0100 or 154 NCAC 02C.0200 Well Construction Standmrts and that a
7.Is this a repair to an existing well: ❑Yes or 2< copy of ft record has been provided to the well owner.
If this is a repair,fill out brown well construction bdbrmation and explain the nature of the
repair wider#21 rernarb section or on the bank o'dris form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple iryeetion or not-water supply wells ONLY with the sane consirud rr,you can SUBMITTAL INSTUCTIONS
submit orefom r
9.Total well depth below land surface: 3 0� (tit.) 24a. For All Wells: Subunit this;form within 30 days of completion of well
For rmthiple wells list all depths if a erent(mmnple-3@200'and 2Q100') construction to the following:
I
Division of Water Quality,Information Processing Unit,
10.Static water keel below top of casing: ft) Division
Mall Service Curter,Raleigh,NC 27699-1617
If water level is above casing,use +'
It.Borehole diameter. 0 (m.) 24b.For Injection 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
1L Well construction method: ry construction tothe following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1634 Man Service Curter,Raleigh,NC 27699-1636
13a Yield m 3 Method of test Blowing-Rig 24c.For Water soonIV&Injection Wells: h1 addition to sending the form to
(gP ) the address(es) above, also submit'one copy of this form within 30 days of
13b Disinfecti on Chlorine Amount fig OZ. completion of well construction to the county health department of the county
type where constructed.
wt....t,r,....r...,,rv..,w.....,t,.FF. i--tarylNaturalRecnurcas—DivisionofWaterOuality Revised Jan.2013