GW1-2021-02509_Well Construction - GW1_20210809

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Larry W. Ferguson FROM TO DESCRXPTION
Well Contractor Name h ft
NCWC 2029-A h ft
NC Well Contractor Certification Number 15.OUTER CASING OwmiddAcswd Wells)OR LINER bfe
FROM TO DIAMEM TffiCBNFSS MATERIAL
Ferguson's Well and Pump, LLC hI 4dh14,RS '- I 6, cs Z
Company Name 1 IlVPTER CASING ORTUSTNG dosed
FROM TO DIAMETER THICI{P1FSS MATERIAL
L Well Construction Permit#: �' 6 d b�a 8 ft ft in
List aU applicable well construction perncts rte.Comfy,State,Variance,etc.)
h it in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE TMC CNFSS MATERIAL
❑Agricultural OMunici blic ft tt in
[]Geothermal(Heating/Cooling Supply) esrdential Water Supply(single) h ft in
❑lndustrial/Commercial ❑Residential Water Supply(shared) I&GROUT
FROM TO MATERIAL EMPLACE WfT METHOD tit AMOUNT
OfiTivation 10 fr' 20 ILConcrete Gravity-Flow
Non-Water Supply Well:
ft it
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK K agplicalde)
FROM TO I MATERIAL I EMPLACEMENT METHOD
OAquifer Storage and Recovery ❑Salinity Barrier h h
OAquifer Test ❑Stormwater Drainage
ft ft
❑Experimental Technology ❑Subsidence Control
X DRILLING LOG attach addifiond d mis if
❑Geothermal(Clused Luup) ❑Tfaucr FROM To DESCRIPTION color hardnew,gollfrock ds elo
❑Geothermal(Heatin Return) ❑other(explain under 421 Remarks)J ft ft.
S ft- ft
4.Date Weil(s)Completed:�( �Well 11>#i h h
5a.Well Location: 7kd- d C
rt ft w e
_5 �'1Ctl'11 (i D n nCr' ft ft.
Fwilility/OwncrName Facility lD#(ifapplicable) h ft. En
90 r-QGi y&la ;Z9'7G o2, ft ft
Physical Addrels rty,and lip 21.REMARKS
�b e/q�
County Parcel Identification No.(PIN) i 1f011�
�A OI1
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(dwell field,one lat/long is sufficient)
3 S'AY`a2�� 6z=N Sz°�-�'3Y. '7/6 ` W
_� Si o sea W 1 n 'tor
6.Is(arc)the weII Cf'Po(s): rmanent or ❑Temporary By sipft ft form I hereby cop*that the wefl(s)was(were)constructed in accordwe
with 15A NCAC 02C.0100 o•15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an e33sting well: ❑Yes or am copy of dds record has been provided to the well owner.
If this is a-pan,}lll our lomwn well construction b#bnnation and explain the nature ofthe
repair under#21 nanartcs section or on the back of thisfo m. 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: s/ construction details. You may also attach additional pages if necessary.
For multiple br#ecdm or non-water supply wells ONLY with due same carstrucoan,you can
.sr bn t are fa m SUBMITTAL INSTUC73ONS
9.Total well depth below land surface: ��� (fk) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths rfdkfferaw(ermnple-3@200'and 2®I001 construction to the following:
10.Static water keel below top of casing: yA A) Division of Water Quality,Information Processing Unit,
if water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 10 (in.) 24b.For lnieetion Wills: I.addition to sending the form to the address in 24.
Rotary above, also submit a copy of this form within 30 days of completion of well
11 Well construction method: rAn struction 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 Servic6 Center,Raleigh,NC 27699-1636
13a Yield(gpm) Method of test
Blowing-Rig24e.For Water Surly&Injection Wells: hr addition to sending the form to
the address(es) above, also suhmnit one;copy of this form within 30 days of
136 Disinfection type: Chlorine Amount, So oz. completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013