GW1-2021-02601_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 DESCRIPTION
Well ConttsctorName & . 00 f`
NCWC 2028-A ft 3 t`
NCWeIIContractorCcrtificationNumber I&OUTER CASING atmdti�ed.wella fORL1N6Rd ble
FROM TO DL4?AXTER' T10� MATERIAL
Ferguson's Well and Pump, LLC f` �* S;m � / S P C 2'
Company Name 16.1NNER CASING OR TUBING. dtw d
FROM TO I DIAMETER I MECRNEM MATERIAL
L Well Construction Permit#: - ft ft ID
List all applicable well construction perndis(r.e.Courdy,Stare,Mari 4 tc.)
tt tt in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO I DIAMEM SLOT SUE ITffiCIffVFS3 MATERIAL
ft ft in.❑Agricultural G1�1£(t�uyeipal/Public
❑Geothermal(Heating/Cooling Supply) estdential Water Supply(single) ft it m
❑Industrial/Commeroial ❑Residential Water Supply(shared) 1&GROUT
FROM I TO MATERIAL FAUI AC (ENT METHOD&AMOUNT
01ni lion 0 ' 20 ft- Concrete Gravity-Flow
Non Water Supply Well: ft ft
❑Monitoring ❑Re overy
Injection Well: iL ft
❑Aquifer Recharge ❑Groundwater Remediation A SAND/GRAVIL PACK e
FROM TO I MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier g ft
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control
29:DRILLING LOG.attadrad&Gmal slieels
❑Geuthtxmal(Closed Luup) ❑Trauer FROM To DFSL211 YON lador,hardness,sWVrock di etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) ft 0yo tt
` r! ft. It
4.Date Well(s)Completed:-� Well W# `f ft' 7O ft C
Sa Well Location: 10.5 "' ft t
45 lv
/i
( hi9� &w e r ft ft
Facility/Owner Name Facility ID#(if applicable) ft t f
_72 m Ar4 i rn l/�a nA iP r- f2 a a tpA✓1c1 ,7_�( ft ft T
Physical Address,City,and Zip 2L REMARKS c;
�Iarvnl)r 17/36gcl I ( () P` d_6 2o1**
County Parcel Identification No.(PIN)
O`
5b.Latitude and Longitude in degtees/ndnutes/seconds or decimal degrees:
2L Certification:
(if well field,one lattlong is sufficient)
N $� D%/.9�lzS W
Signature o ed well Contractor tt
6.Is(ore)the well(s): Gwermanent or ❑Temporary "
By stgrung this form I hereby eer*that dw weA(s)was(were)constructed in accordance
�_� with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 W41 Construcdan Standards and that a
7.Is this a repair to an existing well: ❑Yes or l�tro copy of this record has been pramled to ties well owner.
If this is a repair,J111 aid brawn well conduction information and avlmh the namm of the
repair under#21 ranavb section or on the back of thisfonn 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 muldpk byecdon or non-water supply wells ONL with the same cons&ucdon,you can
,nrb„W oreform SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: �5 (tt.) 24a. For All Wells: Submit this,form within 30 days of completion of well
For mu11iple wells/at all depths if different(exmnpk 000''and 2@100D construction to the following:
10.Static water level below top of casing: /10 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. klq 24b.For Iniection 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
12.Well construction method: ry construction to the fullovtin&
(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 27699-16M
13a.Yield(gpm) �1 Blowing-Rig 24e.For Water Sn piy&hd tioni wdb: In addition to sending the form to
/ Method of test:
the addresses also submit!one copy of this form within 30 days of
136 Disinfection type: Amount
Chlorine So OZ. completion of well construction to l the county health department of the county
where constructed. �
Form GW-1 North Carolina Department of Environment and Natural Resources—1]�vision of Water Quality Revised Jan.2013