GW1-2021-00160_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:
i,C WATER ZONES I
Bobby W. Potts FROM TO I DESCEMON
Well Contractor Name ft ft I
NCWC 2028-A ft. ft
NC Well Contractor Certification Number OUTER CASING wed wtDs �
FROM TO DJAM ,,, IMCKNESS MATERIAL
Ferguson's Well and Pump, LLC 3 RS I'- 17 //vi
Company Name 1t. CASING ORTUBllt1G dosed
FROM TO I DLAMErIZ I MATERIAL
2.Well Construction Peru#• A 6a l - b U �- ft ft in.
List a0 applicable we0 cmOuo6on permits tie.Cow*,State,Variance etc.) R it im
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO I DIAlY=Mt I SLOT SIZE TMCKra s I MATERIAL
ft ft in.
❑Agricultural ❑Muni lie
❑Geothermal(Heating/Cooling Supply) ORCMdeatial Water Supply(single) ft ft
❑ludustriOComnie:reial ❑Residential Water Supply(shared) la.GROUT
FROM 1 TO MATERIAL DeLACVffNTMrM0DaAMOUNT
13hrigation - 0 20 fL Concrete Gravity-Flow
Non-Water Supply Well: ft ft
❑Monitoring ❑Recovery fL ft
Injection Well:
❑Aquifer Recharge [Groundwater Remediation M SAND/GRAVEL PACK(if aryfficWHA
FRAM TO I MATERIAL F1AlPLACEbffiVr METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach additional fibeeft U100095127)
❑Geuthermal(Clustni Loup) ❑Traurs FROM TO DEK3tWnQN caw,hardness,sduroclt 01W M%M d2e,etc
❑Geothermal(Hea' oo' Return) ❑Other(explain under#21 Remarks) fL 20 ft. ,OL
tt ft
4.Date Well(s)Completed: well IDk ft i'sA
5a.Well Location: ft ft
I IWrN Am6ru ft ftDEC
Facility ame Facility 1Dkl(ifppl aicable) ft ft
32 4&fon_?ojPl.j 1-14I7 o WePiit irt,liIt M?Wr R tt
Pbysical Address,City,and Zip ZL REMARKS
�t t Cam to 7C A 8 61l a 9.
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degreadminutes/seconds or decimal degrees: 2L Certification:
(dwell field,one IatAoug is sufficient)
N 5s�a 3,2"37t/8314 w •Zi
/" Signature of eel Coa for
6.Is(are)fhe we11(s): 21fcrmancnt or ❑Temporary By signing dhts form I hereby ae?*that die weA(s)was(were)cwavn+cted in ocaordm+ce
—� with 15A NCAC 02C.0100 or 15A NCAC 02C.0200)Yell Cansin cdon Stwdan s and that a
7.Is this a repair to an existing wed: ❑Yea or l<O copy of dds reowd has been provia6d ro the well owner.
If this is a repab,ftl!out known well construction b#b7nalan and explain the nowe of the 23.Site or additional well details:
repair wader#21 remark;section or on the back of ddsform ins
/ 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 mhddpk hjecam or nosh-water supply we1Ls ONLY wilt dw same oan3trudu9k you can SAL 1N5TUCTIONS
subH&preform
9.Total well depth below land surface: , (ti.) 24a. For AR Wells: Submit this(form within 30 days of completion of well
For multiple wells list all depdts f 4*rert(ermnp/e- 'and 2@1001 construction to the following:
I
10.Static water level below top of easing: (fL) Division of Water Quality,Information Processiaa Unit,
If water level is above casing use"+ 1617 Mad Service Cuter,Rald fir,NC 27699-1617
11.Borehole diameter. tJ (m.) 24b.For Iniectfon Wells: In addition to sending the form to the address in 24a
Rota above, also subunit a copy of this Yours within 30 days of completion of well
11 Well construction method Rotary construction to the folluv6ng:
(i.e.auger,rotary,cable,direct push,eta.)
Division of water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mad Service Curter,Raleigh,NC'27699-1636
13s Yield(Spur) Mdhod of fat Blowing-Rig ?Ae.For Water Suonly&Iaiectio I Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
Chlorine OZ completion of well construction to the county health department of the county
13b.Disinfection type: Amount • where constructed
Revised Jan.2013