GW1-2022-01414_Well Construction - GW1_20220124

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Wen Contractor Information:
ATER ZONES
Bobby W. Potts too To DESCRYHON
well Contractor Name ft M
NCWC 2028-A ft ft. !
M OUTER IN1G WOM OR LINER
NC Well Contractor Certification Number FROM I TO DIAidEM' 1ffiC97ITM MATERIAL
Ferguson's Well and Pump, LLC C2R S IhL, W111T C 2-
Company Name 16 G ORTUEIIN
FROM TO I DIAMZM I 71MENffi4 MATERL►L
2.well Construction Permit". (.lj PIA V ' 631 R ie b>L
List all applicable well constriction pemrits(ie.Comay,SWe,Vartmtce etc.) R ft is
3.WeR Use(check well use): 17.SCREEN
Water Supply coon: FROM ►TO DL 49M :SI OT SIZE TMCtQ�M MATFRML
it I ft fn.
❑Agricultural ❑ pal/Public
ft I ft m•
❑Geothermal(Heating/Cooling Supply) laResideatial Water Supply(single) -
❑1ndtlstrial/Commercial ❑Residential Water Supply(shared) 'a-GROUT
FROM TO MATIMUL EbffLACF 2TCMETHODaAMOUNT
❑ non 0 n• 20 rt Concrete Gravity-Flow
Non-watef Supply well: ft R
❑Monitoring ❑Recovery
ft
Nection Wd n
L•
❑Aquifer Recharge ❑Groundwater Remediation 1%SAND/GRAVEL PACK
PROM TO MATERL\I I EMPIACEM NTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier fa ft
❑Aquifer Test ❑Stormwater Dminage ft ft
❑Experimental Technology OSubsidence Control 20. lAG sh"Gansl meets if
Mmutheamal(Closed Loup) ❑Tracer• FROM I TO DFS(.'RWnON co1w hudnem solUracle etc
❑Geothermal(HeatinWCooling Return) ❑Other( lain under#21 Remarks) ft ft
{ _Sys, M
ft ale
4.Hate Well(s)completes:/7��well IDq S fL ft
52.well Location: da R ft t
Cline f. ft
Farility/Owner Nam Facility MN(if applicable) ft ft
O an-frp 11 Kin &at Arr.l,lCZfA a Ll 1 a a ft 0 ^�
Physical Address,City.and Zip 21.REMARKS
TV-w nsul uGnt'� `+ 5 g3�S(P 3(03a
County 1.11Parcel Identification No.(PIN)
5b.Latitude and Longitude-in degreestminutes/smonds or decimal degrees: 2L Certification:
(dwell field,one lat4ong is sufficient)
p.(D� " `
N ..XA - c s, �62y It w -
S' of ' ed W trac
6.Is(are)the well(s): afermancnt or ❑Temporary By sigrang this form,I hereby=Wy that the well(s)was(wen)constructed to aeconbwe
e�" with 15A NCAC 02C.0100 or 114 NCAC 02C.0200 Well ConsMwilm Sta%*v&and that a
7.Is this a repair to an casting well: ❑Yes or 31 o copy of ids recrnd has beenProvfdui to die well owner.
If this is a repair,fill our brown well aonstruetion bftrnatio►n and esplabn the naft a of the
You
m u
repair under#21 rm m*s section or on dw back of thisform. diagram earn ae the back
coil details:
you may use of this page'to provide additional well site details or well
S.Number of wells constructed: cons traction details• You may also attach additional pages if necessary'_
For multiple h jecaor or non-water supply wells ONLP with the same conafr caom you can SUBTAMAL INSTUCTIONS
submit ore ornc
9.Total well depth below land surface. (}t.) 24a. For All Wells: Submit this',form within 30 days of completion of well
For multiple wells list all depths if e5PAW(amnple-3®200'and 2®1001 construction to the following:
10.Static water level below top of casing: 4_0 A) Division of Water Qm ty,Information Processing Unit,
If ware•level is above easotg,use"+" 1617 Mail Service Center,Raldgh,NC 2769961617
11.Borehole diameter. (in) 24b.For ieetinn Well+: 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
IL Well construction method construction to the following: I%
(i.e.auger,rotary,cable,direct push,etc.) Division of water Quality,Uildergr�d Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
&For Water
Blowing-Rig 24
13a Yield(gym) Methodotceat e. Stironly Iniecti r Wells: In addition to sending the form to
the addmss(es) above, also submit one copy of this form within 30 days of
Chlorine SO OZ. completion of well construction to the county health department of the county
136 Disinfection type Apt where constructed
wr_�ti r. t:..,. of Fmri.mnm. t am Natmal Resources—Division of Water duality Revised Jan.2013