GW1-2021-02569_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 FR�ATER TZIoNES D> tTON
Well Contractor Name
ft
NCWC 2029-A n ,o ft
NC Well Contractor Certification Number 15 R CASING armed-e +ed W&8 OR LINER r Me
FROM TO 'D TffiCHIVESS MATERIAL
Ferguson's Well and Pump, LLC ft. 2 i-
�, G
Company Name INNER CASING OR G dosed
FROM TO I DIAMETER I MUCIENESS I MATIaUAL
L Well Construction Permit#: i a d5 ft. ft in.
List all applicable well conshvetion perndts(Le.Cotmty,State,Variance,etc.)
fL ft is
3.Well Use(check well use): 17.SCREEN '
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNFM MATERIAL
❑Agricultural ❑Ivttmicipalftblic
❑Geothermal(Headug/Cooling Supply) *esidential Water Supply(single) ffi ft in
❑Industrial/Commercial ❑Residential Water Supply(shared) 1S.GROUT
FROM TO MATERIAL. E[PLACEbW4l'METHOD a AMOUNT
0 " 20 ft- Concrete Gravity-Flow
Non-Water Supply Well:
❑Monitoring ❑Recovery to ft
Injection Well: ft ft
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK e
OAquifer Storage and Recovery ❑Salinity Barrier FROM ft. ft To MATERIAL EM14 ACE1ZNTrft'HOD
❑Aquifer Test ❑Stormwater Drainage
ft ft
❑Experimental Technology ❑Subsidence Control ?a BRIia,INGi,OC _atli�titualtfreetai!
❑Geuthtamah(Clused Loup) ❑Tracts FROM To DESt'RIPT ON color,hardnax,■oWrock dze,etc
❑Geothermal(H fing Return) ❑Other( lain under 421 Remarks) ft ft
/ ,/� A to ft
4.Date Well(s)Completed: ` r Well ID# 1� r�7
ft. ft
Sa.Well t
/Location: it f
j �e leer ft ft
Facility/Owner Name _— Fac`{il__ity,,1D#(if applicable) g ft "
SD(�, LInJ_Sr_!4 � Qd_ 1—Ir-'rClmr 73 ft ft w
Physical Address,City,an p ifl '
!4enjcrso►-, -759 „cc4 (��unl
County Parcel Identification No.(PIN) scl.o on
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Ce do
(if well field,one lat(long is sufficient) =
13 _Br�Qtg& q N SA"Ll 3'_ W � � �/ rZ
Signature of 'ficd VJ_ell Contractor ate
6.Is(ors)the well(s): ermanent or ❑Temporary
BY stgrdng I forml 4eby certify that the well(s)was(were)constricted in accrordmree
with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Coiatncaior Standards and that a
7.Is this a repair to an eTdsdng welI ❑Yes or 00 copy of tits record has been provided to the well owner.
If dds is a repatn fill oat brown well construction h fonsaiton eaplabi the natrme of the
repair toiler#21 remmi:s section or on the back of thisforrn. 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.
FormrrAVk b#ection or nor-water supply wells ONLY with the same cones you can
a brit oneform SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: q5 (ft,) 24a. For An Wells: Submit this form within 30'days of completion of well
For—Ihpk weirs list all depAs e6fferod(example-3@200'and 2®1 construction to the following:
nA i
10.Static water level below top of casing. 2f/ (H.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 10 (m.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
12 Well conatructjoa method: Rotary above,
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
13a.Yield Blowing-Rig24c.For Water Sunnly At Injection Wells: is addition to sending the form to
(gpm) Method of test: the address(es) above, also submit one copy of this form within 30 days of
136 Disinfection type: Chlorine Amount: OZ. completion of Well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Waicr Quality Revised Jan.2013