GW1-2022-01311_Well Construction - GW1_20220124

ELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14 WATER ZONES
Bobby W. Potts FROM TO DESCPJMON
Well Contractor Name tt ft
NCWC 2028-A " 0 ft
Of
NC Well Contractor Certification Number 15.OUTER CASING' iced webs OR LINER
PROM TO DIAMETER! 7MCKNFSS MATERIAL
Ferguson's Well and Pump, LLC c
Company Name 16.INNER CASING OR TUBING
FROM TO DIAMd__i THICKNESS IMATERIAL
L well Construction Permit#: ZD Z( — U 0 3 7 D ft n m
List all applicable well construction permits(ce.Corm*,State,Yarlanee etc.) [t ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply wdl: FROM TO DIAMEIFR SLOT SIZE THICICaM MATERL4L
tt ft is
❑Agricultural ❑ paliPublic
ft ft
eothermal(Heating/Cooling Supply) dential Water Supply(single)
❑G
❑Industrial/Commercial ❑Residential Water Supply(shaded) 1&GROUT t
FROM TO MATERIAL EMPLACEMFM MBIHOD&AMOUNT
Ohrigation 0 ft' 20 ft Concrete Gravity-Flow
Non-water Supply Well: ft ft
❑Monitoring ❑Recovery n. ft
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 1A�SAPiDlZRiAVBL PACK M TO I � �e EtcEMM MLr[HOD
❑Aquifer Storage and Recovery Cl Salinity Barrier ft ft
❑Aquifer Test ❑Stormwater Drainage R ft
❑Experimental Technolo&v ❑Subsidence Control 28 DRILLING LOG attadr addttimsd if
❑Geuthermal(Clused Loup) ❑Trager FROM I TO DESCRIPITUN color,Gardaess,soiUrocit etc
❑Geothermal(Heating/Cooling Return) ❑Other( lain under 421 Remarks fL S ft-
ft. ft
a.Date Well(s)completer: wets ID# ft e
5s.Well Location: qh & rt �,
V3 /' C:f2 S R ft
F'ac�ility/Owner Namc a Facility ID#(if applicable) ft ft
J�J liel 5nn 1)A el yl�Qnn4r�oFa A9 7 7K fe ft.
�
Physical Address,City,and Zip 31.REMARIM
1✓lr urn he ,0(_a G I 3`776 C=
AAN 2 4 2U'
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degreeshminotes/seconds or decimal degrees: 22.Certification: 01
(if well field,one laillong is sufficient)/
S' f/Cptfified Wel r
6.Is(am)the well(s): BYernoanent or ❑Temporary By smug this fMM 1 hereby-rt(/y drat the wens)was(were)crostnrcted in accordvice
with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Staadarels and that a
7.1,this a repair to an casting well: [Yes or l3Pio copy ofthis record has been> dto de w fl owner.
ff this is a rep*fill out brown well conduction imfbrnmdron and apkmr due nature of die
repair wader tl21 rommia section or on the back of ddsform 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 multipk byection or non-water supply wells ONLY with fix smne carslruc6an,you can SUBAIMAL INSTUCTIONS
Mbmrit oneforma
9.Total well depth below land surface: y 7S _(tit.) 24a. For AR Wells: Submit this form within 30 days of completion of well
For multiple we11s list all depths if dfetwd(example-3®200'and 2Q100') construction to the following:
i
�O ( ) Division of Water Quality,>Information Processing Unit,
if Static water keel below top of casing: 1617 Man Service Center,Rakigb,NC 27699-1617
If water level is above casing,use
It.Borehole diameter. Q (in.) 24b.For Infection WeRr, In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
12•Well construction method: Rotary consttugtion 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 Center,Rakigb,NC 27699-1636
13a Yidd m Method of test Blowing-Rig 24c.For Water S�nly&JAA- io-Wells: In addition to sending the form to
(gp ) E the address(es) above, also submit one copy of this form within 30 days of
Chlorine 6 OZ. completion of well construction to Ithe county health department of the county
136 Disinfection type: Amount where constructed
i
...... v�...r-...�:....rL...,m...nt Revised Jan.2013
of F i mmrnt and Naoval Resources—Division of Water Quality
m