GW1-2021-02518_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:
Bobby W. Potts FR MAC TTO I DESCRIPTION.___
Well Contractor Name ft 640 ft
NCWC 2028-A tt ft.
NC Well Contractor Certification Number 19.OUTER CASING amid eased wells OR LINER bk
FROM I TO DIAMETER THICKNESS MATERIAL
Ferguson's Well and Pump, LLC ft. ft AS AM "ll / C 2
Company Name 16.INNER CASING OR TUBING
aoao _ a 5 FROM R TO DIAMETER MCIOM MATERIAL
L Well Construction Permit#:
List all applicable well construction permts(Le.Cokotry,State,YartmicA etc.
n ft i><
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO I DIAMETER I SLOT SI E THICKNESS I MATERIAL
ft ft in. ------+
❑Agricultural C £n'et�ial/Public
❑Geothermal(Hcating/Coohng Supply) estdmtial Water Supply(single) it ft
❑Industrial/Commercial ❑Residential Water Supply(shared) "L GROUT
FROM I TO MATERIAL EMPLACEMENTAWIHOD!AMOUNT
0hrigation 0 ft 20 ft Concrete Gravity-Flow
Non-Water Supply Well: ft ft
❑Monitoring ❑Recovery ft. ft
Injection Well:
❑Aquifer Recharge ❑tsroundwater Remediation 1%SAND/GRAVEL PACK e
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft
Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control 211.DRILLING LOG attars additional sheets if
❑Geuthermal(Closed Luup) ❑Tracts FROM TO DESLIUMON cdor hudn WL/rocli etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 RemarksA 0 ft ft
jio ft ft. a C
4.Date Well(s)Completed: Well ID# ft ft
C
Sa.Well Location: ft 71) ft > e
A^r%bVN Le iS fL ft
Facility/Owner Name Facility IDN(if applicable) ft ft
j ai G21�at D�d� g:Z:& t1 �8'�` % a
Physical Address,City,and Yiip �y 21.REMARKS
-A,Q41SY �^ far G~O
County Parcel Identification No.(PIN) p YR-
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
Ir
° Q t /I/ W
signanire o ea Wol c ntraetor ite
6.Is(ale)the well(s): C.cnt or ❑Temporary By sigrmtg des form 1 hereby cer*that the well(s)was(were)constructed w accordmrce
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Wdl Construction StarddM&and that a
7.Is this a repair to an e=isting well: ❑Yes or Ole copy of dds record has been provi&d to the well owmr.
If this is a repatr,fdl out brown well construction brfomtation mid explain rite nahae of the
repair wider#21 remarks section or on the bark of this fare 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»ndtiple infection or mri-water supply wells ONLY with the same eanmuchae,you cm SUBA1177'AL INSTUCTIONS
submit one form
9.Total well depth below land surface: Ids (tk) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if&fferew(example-3Q200'mid 2Qa 100') construction to the following:
10.Static water level below top of casing: A 0 OIL) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
0 24b.For Infection Wells: In addition 11.Borehole diameter. (no) to sending the form to the address in 24a
Rota above, also submit a copy of this,'form within 30 days of completion of l��ell
1L Well construction method Rotary construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Pmgram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a Yield(gpm) Method of teat Blowing-Rig 24c.For Water SnnDls&Injectioa Wells:!In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chlonne Amount: 64 OZ, completion of well construction to the county health department of the county
where constructed
-ay.,..:...---..,e.,.1 V—.1 R.ann„ c-rl;vieinn of Water rhm ity Revised Jan.2013