GW1-2021-02574_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,
Bobby W. Potts FROM4RZOTO� DESCRIPTION
Well Contractor Name fL Q ft
NCWC 2028-A ft ft
NC Well ConhactorCertification Number MOUTERCASIIVG trimrdtir ed_Wells ORLINSR tf hie
FROM TO DW�TFR T1dICIi>VEST MATERIAL
Ferguson's Well and Pump, LLC ft ft Z/w,
Company Name 1(.INNER CASING OR TUBIlNG. elated
^ FROM TO DIMEIF.R TZ;[CKN&4S MAT1�t1AL
L Well Construction Permit#: ))OaO - y11 R R
List all applicable weft construction permits(ne.County,State,Yarimrce,etc.) ft ft fin
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO I DIA11l nut I sI.OT smEE I THIcKNw I MATm1AL
ft ft in
❑Agricultural ❑ paUPublic
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1&GROUT
FROM I TO MATERIAL Df LACKWENTMETHOD&AMOUNT
❑hri lion 0 ft 20 ft Concrete Gravity-Flow
Non-Water Supply Well: ft ft
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundvater Remediation .19.SAND/GRAVEL PACK.Of.arlicable)
FROM TO I MATERIAL I EMPLACENONf NEETHOD
❑Aquifer Storage and Recovery OSalinity Barrier & ft
❑Aquifer Test ❑Stormwater Drainage ft R
❑Experimental Technology ❑Subsidence Control
S0:DRILLING LOG attadi aditiaoal sliriets.
❑Geothermal(Clused Luup) ❑Tracts FROM TO DFSLIUMON color,hardness,sollfroclt an etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft s ft
ft. '!ft
4.Date Well(s)Completed: ..Z Well ID# in ft
S 4c C
52.wen Location: IS75
ft ft e' t
uw� c
CAP-SA �ec IC ft ft
Facility/ ame Facility ID#(if applicable) ft. R
LOUN enrn tt 1 kcL sria',AAnoA aBll8 ft ft
Physical Address,City,and Zip 21.REMARKS
hu(\ or,n b e cl(gg'128-1 ct Sy r,ink
County Parcel Identification No.(PIN) r_rrn,��O ��:0(%
5b.Latitude and Longitude in degrees/minutealseconds or decimal degrees: 22.Certification-
(if well field,one Wong is sufficient)
�3 `'Y9,4P 3!% N ST2�° 9 a l t l/�%/ w
� Sigmnue of ' eel W Coa torn
6.Is(are)the well(s): taPertnanent or ❑Temporary By siV tug this farm,1 hereby aernfy drat the wep(s)was(were)constructed to accordance
with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ❑390 copy of this record has been provided to due well awner:
If this is a repair,full out bm m well conduction information and explain are nature ofdne
repair under#21 nvnarfa section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple agecdon or non-water supply wells ONLY with the smne corubuccoe,you can
Submit oneform SUBMITTAL INSTUCTIONS
9.Total well depth below land surface:_ (S (tl) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depdns fat femur(es Wk-3(a)200'and 2Q100� construction to the follov6ng:
10.Static water level below top of casing: AO 00 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. (in.) 24b.For Injection Wens: 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
12.Well construction method: construction to the fulloming:
(i.e.auger,rotary,rabic,direct push,etc.)
Division of water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mal Service Center,Raleigh,NC 27699-1636
13a.Yield OUR) Method of test: Blowing-Rig 24c.For Water Sm iply Bt Inlectio�Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
Chlorine OZ. completion of well construction to Ithe county health department of the county
13b.Disfmfection type: Amount 7
where constructed- I
Form GW-1 North Carolina Department of Environment and Natural Resources—D ision of Water Quality Revised Jan.2013