GW1-2021-02512_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.WATER ZONES
Bobby W. Polly�s FROM TO DESCRIPTION.
Well Contractor Name R 2 30 ft
NCWC 2028-A ft ft
NC Well Contractor Certification Number 1S OUTER CASING or multi-cased webs OR LINER bk
FROM TO DIAMSPER' MCMIM MATERIAL
Ferguson's Well and Pump, LLC R R ,As '
Company Name 16.INNER CASING OR TURING ckwA
FROM I TO I DIAMETER I TffiCENM MATERIAL
L Wen Construction Permit#: t�DaD ' D 01 9 a— R ft in,
List all applicable we0 consbncdon permits(le.Comely,Stale,Variance,etc.)
R R �
3.Well Use(che&well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT STLE TEucxivESS MATERIAL
ft ft in
❑Agricultural ❑Muni he
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEWM14CMiOD&AMOUNT
❑lrri lion 0 R 20 ft Concrete Gravity-Flow
Non-Water Supply Well: ft ft
❑Monitoring ❑Recovery R R
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK e
FRAM TO I MATERIAL EM1LACEM1 VT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft
❑Aquifer Test ❑Stormwater Drainage R ft
❑Experimental Technology ❑Subsidence Control 20,DRILLING LOG atCadi additional reefs if
❑ mutheamal(Closed Loup) ❑Ttautz FROM I TO DFStIdMON color,hwtn sWb*m t 6k VWIM d2e,etc
❑Geothermal 04eatingACooling Return ❑Other( lain under 421 Remarks n
R ft.
ft ft
4.Date Well(s)Completed: Well ID►t {t ft
51.Well Location: < fL S ft
e_ R ft
Facility/Owner Name Facility IM'(ifapplicabte) {t ft
07 PIAne,f1 2 14 66 va 1c- a&30(a R ft
Physical Address,C' , d Zip 21,REMAPJZ
County Parcel Identi6cationNo.(PIN) tore—
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
350 l liv ��°.3-5tgr" ��// w /
Signature o 'fi ell. tractor m
6.Is(are)die well(s): 4.rmWcnt or OTemporaty By signing dais fora;I hereby-r*that the wens)was(were)constructed in accordance
with 15A NCAC 02C.0100 or ISANCAC 02C.0200 Well Constr edon Standard;and that a
7.Is this a repair to an eristing well: ❑Yes or 090 copy of this record has been provided to the well owner.
If this is a r+epatr,fdl our brown well eonsouction Information andexplain the nattoe of the
repair wader#21 ranarks section or on the bank of dds form. 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 wells constructed: construction details. You may also,attach additional pages if necessary.
For multiple b#ecbom or noun-water supply wells ONLY with dx satme casstracriom,you can SUBMITTAL INSTUCTIONS
submat oneform
9.Total well depth below land surface: �jz� (fL) 24a. For AR Wells: Submit this form within 30 days of completion of well
For nul ipfe wells list all depdts lfdi,(Jerott(ermmple-3Q200'and 2Qa 100') construction to the following:
10.Static water level below top of easing: oZ (ft.) Division of Water Quality,Information Processing Unit,
If water level is above ombsg use"+ 1617 Man Service Center,Raleigh,NC 27699-1617
11.Borehole diameter.
0 (ice) 24b.For Inkcthm 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 vti'ell
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
a.Yield m 3 Method of test: Blowing-Rig 24c.For Water Stironly—Inkcti Wells: In addition to seceding the form to
13
(gp ) �� the address(es) above, also sub6it!one copy of this form within 30 days of
13b.Disinfection Chlorine Amount: yea OZ. completion of well construction to the county health department of the county
type where constructed.
Revised Jan.2013