GW1-2021-02571_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. Potts FROM TO IDESCRIPTION
ft
Well Contractor Name
NCWC 2028-A to ft
15.OUTER CASING edit rased we�a OR LINER a bk
NC Well Contractor Certification Number FROM TO D7AMEIER IEIC»ESS MATERIAL
Ferguson's Well and Pump, LLC Q, � (� � �S '� 2-4,IAY I M5 2-
Company Name 16.dos INNER CASING OR TUBING dosed 1 - b�3v o FROM To D T, s MATERIAL
2.Well Construction Permit#: fL in.
List all applicable well construction permits(Le.Courtly,State,Variance,etc.) g• ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: mom ft. ft DL4bC � SUn SM
❑Apeultural ❑Mani lic
in
❑Geothermal(Heating/ ooling Supply) esidmtial Water Supply(single)
ft
ft
❑lndustrial/Commercial ❑Residential Water Supply(shared) I8
FROM TO MATERIAL McLAC6l�JV'I'A!P riiOD A AMOUNT
01ni lion 0 rt 20 ft Concrete Gravity-Flow
Non-Water Supply Well: 2 ft
❑Monitoring ❑Recovery
ft ft
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK e
FROM TO I MATERIAL I FMPLA 11 MOD
❑Aquifer Storage and Recovery ❑Salinity Barrier B. ft
❑Aquifer Test ❑Stormwater Drainage 2 ft
❑Experimental Technolo&v []Subsidence Control 2t1.DRILLING LOG attadu additional abeets it
❑Gcuthetmal(Ciustxl Loup) ❑Tracer FROM I TO DEst.•It MON color bands solv;& ntc
❑ rm Geotheal(Hen' olin Return) ❑Other(explain under#21 Remarks) fL 2V ft
fG �f'' ft
4.Date Well(s)Completed: Well ID# fc O It,
Sa.Wen Location: ft S ft
�Phe.n Ae jr bt'LS ft ft. p J
Facility/Owner Name Facility MN(if applicable) ft ft
��1 I SJi,t�tr �rcurhl2_A 1_e1te3t(_r d 8fAlY ft
Physical Address,City,and Zip 21.RFMAREM
-Nu nenrn h t- C1 rl pl q 14I LrL&0666V
county Paroel Identification No.(PIN)
Sh.Latitude and Longitude in degreeshminutes/seconds or decimal degrees: 22.Certification: -
(if well field,one IatAong is sufficient)
N Ssz°�0 ag.'IM_ w Z
��{/ s' o fled' Well.fntractor
Date
6.Is(are)the well(s): 01i crmanent or OTemporary By stpung this fans,1 hereby aerVY' that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an e=istmg well: ❑Yes or BNo copy of this record has been prvvtded to the well owner.
If thts is a repair,fill out blown well construction Womra Lion and csPlact the nature of the Site diagram or additional well details:
repair ruder#21 ranarta section or on the back of dds form 23.
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 byeclm or nor-water supply wells ONLY with the sere cavcs&uctiae,you can 3UBAUTTAL INSTUCTIONS
subr at one form
9.Total well depth below land surface: as, (tt) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if afijJ'emtt(--*e- Q200'and 2Q100) construction to the following:
10.Static water keel below top of casing: (ft) Division of Water Quality,Information Processing Unit,
1617 Mail Service Center,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter. 10 (ID)
24b.For Iniecdon Wells: In addition to sending the form to the address in 24a
Rotary above, also submit a copy of this form within 30 days of completion of well
li Well construction method construction to the following:
(Le.auger,rotary,cable,direct push,etc.) Division of Water Quality,Underground Injection Control Program,
1636 Man Service Ginter,Raleigh,NC 27699-1636
FOR WATER SUPPLY WELLS ONLY:
Blowing-Rig 24e.For Water Stmnly A IiJet! Wells: Tn addition to sending the form to
13a.Yield(gpm) Method of teat: the address(es) above, also submit'one copy of this form within 30 days of
Chlorine completion of vvell construction to the county health department of the county
13b.Disinfection type: Amount SU OZ' where constructed
>vnKh r amlina rk n. rtmnnt of F.nvimnment and Natural Resources—Division of WaterYQuality Revised Jan.2013