GW1-2021-02511_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:
14.WAT'ERZONES
Bobby W. Potts FROM TO I DESCItIPTION
Well Contractor Name ft f`
NCWC 2028-A ft. ft.
i
NC Well Contractor Certification Number 15.OUTER CASING or m�ti-eased ee0s LINER f OR 6le
FROM TO I DIA?JXTER I TEacxr1FSS I MATERIAL
Ferguson's Well and Pump, LLC h- C 2
Company Name 14L INNER CASING OR TUBING.
./ FROM TO I DIAMETER I MECENESS MATERIAL
2.Well Construction Permit#: elf�" �5/ fL ft to.
List all applicable well construction perfts(1 .County,Stale,VmiawA etc.) ft ft in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DLA IFR ME SLOT SIZE TEEICKNFSS MATERIAL.
ft ft in
❑Agricultural ❑ ipal/Public
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft
❑Industrial/Commercial ❑Residential Water Supply(shared) i&GROUT
FROM I TO MATERIAL EMPLACEh4XNT N=OD&AMOUNT
❑hri lion 0 ft 20 ft Concrete Gravity-Flow
Non-Water Supply Well: ft ft
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK Of 3wlkable)
FROM TO I MATERIAL EMP'LACEMVFr INP 1'ILOD
❑Aquifer Storage and Recovery ❑Salinity Barrier fL &
❑Aquifer Test ❑Stormwater Drainage fL &
❑Experimental Technology ❑Subsidence Control
2&DRILLING LOG.' adifimA if
❑Geuthtamal(Clused Luup) ❑Trd= FROM I TO DFSC tIPTI cdor,huda soNroclr etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks ft 71 ft a
(a ft --TZ
4.Date Wens)Completed:Well ID# ft
Sa.Well Location: n ft ft
fir fLY�/�- 0 7 ft ft
I
Owner Name Facility ID#(if applicable)
ft ft
d%lifullgia ft ft
Physical AddreWCity,and Zip 2L REMARKS a
—211 -yl� ,73`� �,TtL I C, oU��o
County Parcel Identification No.(PIN) ,L
5b.Latitude and Longitude indegrees!®nutes/swouds or decimal degrees:
(ifwell field,one lat/long is sucient) 22.Ce 'on: ` • v
ffi
, Sy2h 130q,� N 't�°3`s �S�QY� t W '
Signature-OfCe6fied Well Contras r
6.Is(are)the well(s): BPernranent or ❑Temporary
BY sigrcng tics farm,1 Prrreby certify that die weA(s)was(were)constructed in accordance
with IBA NCAC 02C.0100 or ISANCAC 02C.0200 Well Conshw im Standvds and drat a
7.Is this a repair to an existing well: ❑Yes or o copy of dais record has been provided to due well owner
If this is a repair,fill out known well cono7wfion reformation and esplam the nature of are
repair raider#21 rvnarks section or on the back of thisfmm. 23.Site diagram or additional wen 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 multiple injection or iron-water supply wells OWLY with the same cansbudion,you can
submit are form SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: �/ZS (}I-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths rf duffer lit(example-3@200'and 2@I001 construction to the following:
10.Static water level below top of casing: �y (ft) Division of Water Quality,Information Processing Unit,
If water level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter. (in) 24b.For Iniection Well+: 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
12.Well construction method: Rotary construction to the fulluaing:
(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
Blowing-Rig24c.For Water Sa r&Iniectiaa Wells: In addition to sending the form to
13a Yield(gpm) Method of test: the address(es) abave, also submit one copy of this form within 30 days of
13b.Disinfection type:
Chlorine Amount: oz. completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Euvironment and Natural Resources—D'vision of Water Quality Revised Jan.2013