GW1-2021-02537_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'TER T
ONES DESCRIPTION
Well Contractor Nam k' ft
NCWC 2029-A tL / it
NC Well Contractor Certification Number 15.OUTER CASING ffifewr mdt4 cased welts OR LINER bk
FROM I TO DIAMETER THICENESS MATERIAL
Ferguson's Well and Pump, LLC 0 it AS w
Company Name 16.INNER CASING OR G dowd
2O� FROM TO DIAMETER THIC raM MATERIAL
2.Well Construction Permit#: � 66 LCO ft ft ip
List all applicable well conserwilm pewits(Ie.Cowdy,State,Variance,etc.)
ft ft le.
3.Well Use(check well use): 17.SCREEN
Water Supply Wen: FROM TO DIAMETER I SLOT SIZE TEMCKNFSS MATERL4L
❑Agricultural 0Mj3p Tp'dJPubhc ft ft in.
R% t
❑Geothermal alcating/Cooling Supply) dentiai Water Supply(single) R ft
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT
FROM TO MATERIAL EAFLACEMENf METHOD ta.AMOL1Nr
❑ tion V ft- 20 rt Concrete Gravity-Flow
Non-Water Supply Well:
ft ft
[]Monitoring ❑Recovery
Injection Well: & ft
❑Aquifer Recharge ❑Groundwater Retnediation 19.SAND/GRAVEL PACK e
FROM
❑Aquifer Storage and Recovery ❑Saln ft
TO MATERIAL E11lPLACEHffi�f111EIHOD
❑Aquifer Test ❑Stormwater Drainage
ft ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach addifiiand abtafa if
❑Gcuthcrmal(Closed Loup) ❑'lot'at= FROM TO DESCRIPTION color trarda .dUraek as a�
❑Geothermal(Heatin Return) ❑6tOther(explain under 421 Remarks) V ft ft
ftq- ft
4.Date Well(s)Completed: Well ID# R ft.
Well Location: ft it e
3.
,1(aAU ern(,) & it
Facility/ ame Facility lD#(ifapplicabie)
ft ft ,.
Jill C )(8 YOl-r I2oAc r/4/rU1$.t.c) 9 973 0 ft ft
Physical Address,City,and Zip r2L REMARIG9
tEncom 5t)61 P Utiv
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degnees/minutes/seconds or decimal degrees: 2L Certification:
(if well field,one Wong is sufficient)
3S°3dt;(YrWAtt N a2-°15 (�2, 7Z rl W -:&& /I/ —
Signatum of fied ell Con for
6.Is(are)the well(s): ®'Permanent or ❑Temporary By mpft this fors;I hereby certtfy'that the weD(s)was(were)co nstn cted In accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Slardads and that a
7.Is this a repair to an existing wen: ❑Yes or copy of d&record has been provided to the well owner.
ydds is a repair;ffl and known well cortsouction 6fomIattan andesplam the not=ofthe
repair wider#21 remark section or on the back of thisform. 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 wens constructed: / construction details. You may also attach additional pages if necessary-.
For multiple bgecam or non-water supply wells ONLY with the same eanabudiaaz ym can
ai&W one fro SUBMITTAL INMCTIONS
9.Total well depth below land surface: ��S (ft) 24a. For An Wells: Submit this form within 30 days of completion of well
For muhiple wells list aU depths if&ffer ent(eranple-3 00'and 2-@100� construction to the following:
10.Static water level below top of casing: A 0 A) Division of Water Quality,Information Procwsmg Unit,
If water level is above casing,use"+" 1617 Man Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 10 (in.) 24b.For Injection wells: In adtittion.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
12.Well construction method: wnstruction to the following:
(i.e.auger,rotary.cable,direct push,etc.)
Division of Water Quality,;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 16M Man Service''Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of tat: Blowing-Rig 24c.For Water Supply&Iniectlnn Wells: In addition to sending the form to
the addresses) above, also submit tme copy of this form within 30 days of
Chlorine 6 OZ. completion of well construction It to the county health department of the county
13b Disumfection type: Amount where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013