GW1-2021-02536_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 FROM TO DFSCPJM0N
Well Contractor Name
NCWC 2028-A ft ft
NC Well Contractor Certification Number 15.OUTER CASING mdtl mud wel a OR LINER applicable)
FROM TO DIAMETER THICKNESS . x
ERIAL
Ferguson's Well and Pump, LLC � r �'in 2�i,'
Company Name 1C INNER CASING OR TUBING dined4
PROM DIAMETER THIG7iTiE9S MATFRiAL
L Wen Construction Permit#: AWL- b n I'i� ft TO rt in.
List aff applicable well construction permits(Le.Comity,State,Variance,etc.) it it is
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM I TO DIAMETER SLOT STLE THICKNESS MATERIAL
ft tt �.
❑Agricultural ❑ lic
❑Geothermal(HeatinWr-oling Supply) esidential Water Supply(single) ft ft in.
❑Industria iCommercial ❑Residential Water Supply(shared) FR GROUT
FROM TO MATERIAL PTNPLACE.NffiHT111ECHODtAMOUNT
01ni tion 0 ft 20 ft Concrete Gravity-Flow
Non-Water Supply well: ft ft
❑Monitoring ❑Recovery
O ft
Injection We&
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVEL PACK e
FROM TO I MATERIAL IFMPLACENIENrhwniOD
❑Aquifer Storage and Recovery ❑Salinity Barrier g ft
❑Aquifer Test ❑Stotmwater Drainage g ft
❑Experimental Technology ❑Subsidence Control 20 DRILLING LOG attach addltionrd eheeta if
❑Gnuthtamal(Closers Luop) ❑Traaa' FROM I TO DESC'ItIP1'ION color,hardn soluroclr etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#2l Remarks fL 1 50ft
ft. ft
4.Date Well(s)Completed: Well IDH 26 ft t ft
5a.Well1ocation: tL ft
f t lhi Moo �f_�C.s & ft
Facility/ caner Name Facility IDN(if applicable) D, ft
tb&A 31.ce.4 �g�t uQ a8_i�oLo & ft a�
Physical Al dress,City,and Zip 21.REMARKS
�t�ncD�i�e. 7GA-1e it4.3leG366t)
County Parcel Identification No.(PIN) rj4�O
5h.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.CertiHcad n:
(if well field,one lat/long is sufficient) \- Q
a6,�7 / / / W
Signature o fied Well fntrac r to
6.Is(are)the WCII(s): Crnlanmt UT OTCn1pOTary gy si dds form,I hereby certify that doe wen(s)was(were)constructed in accordwce
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy of dds record has been provided to'dre well owner.
If dds is a repair,fill out baron well construction bjamarion and explain the nature ofdue 23.Site diagram or additional well details:
repair under#21 nentarb section or on due back of ddsfmm
/ You may use the back of this page to provide additional well site details or well
S.Number of welts constructed: construction details. You may also attach additional pages if necessary.
For multiple tryemon or not-water supply wells ONLY wide the sane 7.nstrue6an,you can SUBMITTAL INSTUCTIONS
submit one form
9.Total well depth below land surface: C (fL) 24a. For AB Wells: Submit this form Nvithin 30 days of completion of well
For multiple wills list all depds if&ff-vO(—ple-3®200'and 2Q100') construction to the following:
10.Static water level below top of casing: ,�/) 00 Division of Water Quality,Information Processing Unit,
If water level is above casing,use„+„ 1617 Mall Service Center,Rafeigkl,NC 27699-1617
11.Borehole diameter. 10 (in.) 24b.For Iniection 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 well
12.Well construction m,d,,d: Rotary construction to the folloving:
(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 27699-16M
13a.Yidd(gpm) Z— Method oftest: Blowing-Rig 24.For Water Stmnh+&Injection Wells addition to sending the form to
the address(es) above, also submit!one c of this form within 30 days of
Chlorine 5'Q OZ. completion of well construction to the county health department of the county
13b.Disinfection type: Amount: where constructed
xt—u ra...r:..n rl.. t—nr of Rnvimnment and Natural Resources—Division of Water Quality Revised Jan.2013