GW1-2021-02586_Well Construction - GW1_20210809

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor7nformadon:
14.WA1ERZ0M
Bobby W. Potts mom TO DESQUPTION
Well Contractor Name B f
ft ft
NCWC 2028-A
NC Well Contractor Certification Number 1R5.OUTEACASIPIG ar"Ma�ed.;reilsORLINERd 6k
FROM TO DIAMETER i TffiCIaVESSS I MATERIAL
Ferguson's Well and Pump, LLC k 0 rt a Y" Z/�O 2
Company Name 16.INNER CASING OR G two6ennA dosed
FROM TO I DIAMETER I IMCI04M I MATERIAL
2.Well Construction Permit M �a,I b6 a S-7 & ft. I ;a
List all applicable weft constrwiion perndts(e.County,State,Variance,etc.) R ft in.
3.Well Use(check well use): 17,St:'REEN
Water Supply Well: FROM To DIAbWrER SLOT SIZE TMCEN SS MATERLAL
ft ft in. ;
❑Agricultural ❑ paUPublic
❑Geothermal(Heating/Cooling Supply) 2cidenhiil Water Supply(single) n ft m
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT
FROM TO MATERIAL EmK ACEW1ENT MrMD&AMOUNT
Oh-rigation 0 ft 20 ft- Concrete Gravity-Flow
Non-Water Supply Well: ft. ft
❑Monitoring ❑Recovery
Injection Well: iL ft
❑Aquifer Recharge ❑Crrounchvater Remediation 19.SAND/GRAVEL PACK e
FROM TO I MATERIAL IMMAMUNTMEMOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control
2&DRILLING LOG attach addiiimd idn is U
❑Geothermal(Closed Loop) ❑Trau yr FROM TO DESLTt MQN color,bardn sdlhocir mie,min d2e,etc
❑Geothermal(Heatin Coolin Return) ❑Other(explain under 421 Remarks) ft ^0 ft a.
ft ft5dJq t'
4.Date Well(s)Completed: Well ID# ft .0 IL (A
Sa.Well Location: tt ft / e
U �t✓1 CAT�n:: +/ ft ft
Facility/Owner Name / -n c(F,acility ID#(if applicable) ft ft
Q` q CG k4 rhf .F.,}'(yl L-e-1 C46 / �O 7/{O ft ft Q 1&
Physical Address,City,and Zip 2L REMARKS
�t.c.n�mb� Da 5'
County Parcel Identification No.(PIN) t.0� CJ6
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latAong is sufficient) 22 Ce oa:
fS���i�f�d r/ N S?R°�/ 6,�r�/6 /" w12AA.IV
Si&turgf fied Well a r tt
6.Is(are)the weil(s): O'PCrmanent or ❑Temporary
By s[grdrtg dds forrrR I'&;reby oerrtfy that the weU(s)was(were)constructed in accortiauce with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 WeU Construction Standards and that a
7.Is this a repair to an existing well: Oyes or copy y'dus record has been provided to due well owner.
If this is a repair;fell otd brown well conduction ddbn•rnation and explain the not=offix
repair under#21 rmia?As section or on flee back of thus 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 nnldpk tryectton or non-water supply wells ONLY with due sane contrition,yai can
submit cute form SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: AA5 (fit) 24a. For All Wells: Subunit this form within 30 days of completion of well
For»wlnpk wells list all depths if dfferent(example-3@200'and 2@1001 construction to the folio-Acing:
10.Static water level below top of casing: �V 11 A) Division of Water Quality,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Curter,Raleigh,NC 27699-1617
11.Borehole diameter. 120 0-) 24b.For Infection Wens: 1.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
12.Well construction method: Rotary construction to the folloming:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Tenter,Raleigh,NC 27699-1636
13a Yidd Wm) / f Method of test Blowing-Rig 24e For Water ply&Injectoa wells:' In addition to sending the form to
the address(es) a also submit one copy of this form within 30 days of
13b Disinfection type: Chlorine Amount. 0S OZ. completion of well construction to the county health department of the county
where constructed i
Form GW-1 North Carolina Department of Environment and Natural Resources-D�vision of Water Quality Revised Jan.2013