GW1-2021-02584_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:
L 14.wATER zoNEs
Larry W. Ferguson
FROM TO DESCRIPTION
Well Contractor Name ft It
NCWC 2029-A ft 7/7 ft
NC Well Contractor Certification Number 15.OUTER G ar m�ficaSed well) OR LINER>f bk
FROM TO I DMAEr R I THICKNESS I MATER AL
Ferguson's Well and Pump, LLC f` ZIA jR / 2
Company Name 16 INNER CASING OR TU13Tr1G dosed
D Q FROM TO DIA11dET'ER THICKNESSS MATERIAL
2.Well Construction Permit M ft ft m
List all applicable well construction permits rLe.Cahmty,State,Variance,etc.) f, ft in,
3.Well Use(check well use): !7_SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERUL
ft ft in
❑Agricultural =esidential
Public
❑Geothermal(Heating/Cooling Supply) Water Supply(single) ft ft
❑IndustrialiCommercial ❑Residential Water Supply(shared) lit GROUT
FROM TO MATERIAL FblPLACEbIENl'METHODBf.AMOUNT
❑ lion a ft' 20 rt Concrete Gravity-Flow
Non-Water Supply Well: ft ft
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK df axiticaMe)
FROM I TO I MATERIAL I BeLACEhffi`tT1AWMOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft.
❑Aquifer Test ❑Stormwater Drainage & ft
❑Experimental Technology ❑Subsidence Control
29.DRILLING LOG attadA aditiaasi dreehs if
❑Geuthertnal(Clusod Luup) ❑'ler'Utx FROM TO DESC1uPT oN cdor,hardn sw1frock m dr
❑Geothermal(Heatin lin Return) ❑[[other(explain under#21 Remarks) o ft 13 ft
fL S ft
4.Date Well(s)Completed Well JIM �3 & ft A
Sa.Well Location: ft ft t c
F �1� ft ft
Facility/Owatzk4ame Facility 1D#(dapplicabbl}le) ft. ft
51bN 4 14hn6 1 V CA UPP()��1 T`t�1 ft ft 1
Physical Address,C' ,and Zip 2L:REMARKS
unty Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: i
22.Certification:
(if well field,one tat/long is sufficient)
`02$�2�72�N ,zy3�tSSf2U(0 W
SiFniixrt of fled Well Con tat
6.Is(are)the well()): l�Permaaeat or ❑Temporary By yfgnirg Mis forn'l Itneby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construtaim Stmulan s and dhat a
7.Is this a repair to an existing well: ❑Yea or []Nn copy of this record has been provided to due well owner.
If 41as is a repair,f ll out known well construction h fomnaaton and esplain the nature of the
repair under#21 remarks 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
S.Number of wells constructed- construction details. You may also attach additional pages if necessar).
For m krpk irrfecdon or non-water supply wells ONLY with dw scone awustradiasr,you can
sub,rXit one f„m f SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 3 P5 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if aiiferent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: is (ft) Division of Water Quality,Information Prvceasing Unit,
if water level is above easing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 10 (in.) 24b.For Injection Well): 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
IL Well construction method: ry rAmtruction to the following:
(i.e.auger.rotary.cablcq direct push,etc.)
Division of Water Quality;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 16M Mall Service Center,Raleigh,NC 27699-16M
13a Yield(gpm) O Method of test Blowing-Rig 24c.For Water SuDDly&IniftVan Wells: hi addition to sending the form to
the address(es) above, also sW mnit one copy of this form within 30 days of
Chlorine �� OZ. completion of well construction to the county health department of the county
13b Disinfection type: Amount where constructed.
Form OW-1 North Carolina Department of Environment and Natural Resources—Division of Wafer Quality Revised Jan.2013