GW1-2022-01314_Well Construction - GW1_20220124

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This term can be used for single or multiple wells
I.Well Contractor Information:
µ,, I'L WATER ZONES
Bobby W. Potts FROM TO DESCRIPTION
Well Contractor Name f 51 ft
NCWC 2028-A ftMA
ft.
ar
NC Well Contractor Certification Number I.S.OUTER CASING > d w� OR lzm
FROM I TO DIAMETER' I IMCSNFSS I MATERIAL
Ferguson's Well and Pump, LLC rt 5-lee l
company Name 16.INNER CASING ORTUBING Bused
FROM TO DL4NM'ER TMENESS MATERIAL
L Wen Construction permit a: 2DZ0 —h b�9. ft ft is
Lul all applteabk we0 tons:&wdon permits(ce.Coiody,Start,Yarimnce,etc)'
R ft
3.Well Use(check well else): 17.SCREEN
Water Supply Well: FROM To DIAMETER SLOT SPLE IMCKNFSS MATFRL►L
ft ft in
❑Agricultural ❑ pal/Public
eothetmal(Heel hn s 0<esideatial water S fe
❑G ft. m
❑Industrial/Cornmercial ❑Residential Water Supply(shared) IS.GROUT
FROM TO MATERIAL McL4.CEbtF1`Tr METHOD&AMOUNT
011rigation 0 ft. 20 ft Concrete Gravity-Flow
Non-Water Supply well: ft ft
❑Monitoring ❑Recovery
Injection Well: ft ft
[]Aquifer Rocharge ❑Groundwater Remediation B.SANDIGRAVSL PACK(If anficalble
FRAM TO MATERIAL EbUM METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier R ft
❑Aquifer Test ❑Stotmwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control 21L DRILLING LOG attadr 8"do d Sheets if
❑Geuthermal(Clusexl Loup) ❑Tracer FROM I TO DFALIttMON color boAnem solUrocit Mle,Milk d2P,etc
❑Geotheamal(Heating/Cooling Return) ❑Other( lam under 421 Remarks) Q R A0 f.
/J 7 ft ft a
a.Date Well(s)Completed:��Well EM �✓ e
ft D ft
5a.Well Location: rz [t r (C-
aAn 1),knQP✓ ft ft
Facili Owner Nam �- Facility ID#(if applicable) ft ft r,
yin! LStli e,( ft ft.
Physical Address,City,and lip 21,RFMORrrs
�I t�lrrovrlht= C1-7&19a) 916000
county Parcel IdentiticationNO.(PIN)
5b.Latitude and Longitude in degmuhniontes/seconds or decimal degrees: 22.Cerdfieation:
(if well field,one lat/long is sufficient)
sib o Cert;Le�well Co �
If
6.Is(are)the well(s): ermanent or ❑Temporary By agrrmg duffarm,1 hereby cer*that the wefl(s)was(were)consinscted in accordance
with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 well Constrwam Stmrdan*and that a
7.Is this a repair to an existing welk ❑Yes or Ofo copy of ft record has been prvvitkd to the well owner.
If skis it a mpain fill cad blown well consbuetion b#ormation and explain the native of the
repair under#21 renarkv section or on tie back of Aisform 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 webs constructed: ! construction details. You may also attach additional pages if necessai)'.
For multiplebgecaw or non-wafer supply wells ONLY with the same;;7Vu xiar,your can SUBMITTAL INSTUCTIONS
subniit
9.Total well depth below land surface: / ([t.) 242. For AB Wells: Submit this,+form Nvithia 30 days of completion of well
For multlpk wells list all depths if�erent(ea:anple-3P00'and 2Q1001 construction to the following:
10.Static water lewd below top of casing: /11
n 0 (R) Division of Water Quality,Information Processing Unit,
If orate►level is above casing,use"`+ 1617 Mail Service Center,Paid&,NC 27699-1617
It.Borehole diameter. 15 (m.) 24b.For Iniectiion 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
IL Well construction method Rotary construction 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,Raleigh,NC 27699-1636
Yield m S Method oiteat Blowing-Rlg 24c.For Water Saooly&Iniee Wells: in addition to sending the form to
13a
Win) the address(es) above, also submit one copy of this form within 30 days of
ClllOnn@ r completion of well construction to the county health department of the county
136 Disinfection type: Amount ��� OZ• where constructed
II
l r. u r—i;n ri—tmnni of Fmrimnment and Natural Resources—Division of Water Quality Revised Jan.2013