GW1-2022-03918_Well Construction - GW1_20220412

WELL CONSTR—MON RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor bnformstion:
Bobby W. Potts 1 4TERZONBB DEacRMON
Well Contractor Na ft
NCWC 2028-A " f49 f`
NC Well Contractor Certification Number I.S.OUTER CASING ���
PROM TO DIAMETER iffiClSS MATERIAL
Ferguson's Well and Pump, LLC tq ! • /6 r S c ?J
Compatry Name 16 INNSR G ORTURING
FROM TO DIAMETER TMCHMM MATERIAL
2.wen Construction Permit a: 3(aft 518- 01 ft
Listallopplieabk well corubrredonpowdis(ee.ComV.Stage,Vartore etc.)
R h in. .
3.Well Use(the&well rase): 17.SCREEN
Water Supply Wen: mom To DIAMELFR sLOT SM THIQ MATQtIAL
ft ft. fn
❑Agricultural ❑ lic
ft
❑Geothetmal(Headn&Cooling Supply) tiai water Supply(single) it m
❑lndtutriaUCommercial ❑Residential Water Supply(Shared) 11 GROUT =
PROM I TO MATERIAL EMPLACDONTMEffiOD A AMOM
❑ tiara 0 R. 20 ff. Concrete rpravity-Flow
Non-water supply well:
rc ft
014onitoring ❑Recovery
hr Wem. ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation M SAND/GRAVEL PACK Of avolighle)
PROM TO MATERIAL IEMPr ACEMEvr METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. &
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control
Zd Dd2IL1JXG LOG alradr adiimsl sbesls R /
❑ muthesmal(Closed Loup) ❑Trae a PROM TO DESCR1p1TON rotor tusdn .amacu WX asift She,etc
❑Geothermal(Hen Return) ❑Otha(explain underl121 Remarks ft 20 n" Q
2 f` 30 f`
a.Daft well(s)Completed: wen M# it
Ss.Well Location: 35
R d S ft
tyawdx
Mwr►c N tsrti 14 k ft ft
Facility/Owxr Name Facility M#(if applicable) ft, ft _
l Wt 1A r1,.tVto­ /W" N1 mrsbaI I QP15.3 ft ft F P,a" r.A"•
Pbyncal Address,City,and Zip Zl.RnIMM APR 12
NYZt l�.Son gZg9 -51 -30"7 `
County PnoelIdcntilicationNo.(M)
Sb.Latitude and Longitude in degmeahnimitediecends or dermal degrees: 2L Cerdfication: I f v�riiv UNI
(if well field,one latllong is sufficient)
s� •S&ckG N 9)l ,qrI f '1PV.A; r W �J� Lj J&6�� AF Z
Sifnature of eel Wall Contractor
6.Is(are)the well(s): elr.m nent or ❑Temporary By,ivft dds fom 1 hereby err*drat the w fi ft)was(tome)oorsAucad in aecordoree
with 15ANCAC 02C.0100 or ISANCAC;02C.0200 Wel1 Coruaeetrar Stmtd n*and drat a
7.Is ft a repair to an elastmg weld: ❑Yes or 21<1_ copy of dds reeondhas been prodded to die well owner.
Ifdds is a repair,fill out kiown well oo a wcrion bo"notion and arplaot due nature of the or additl�nal wen details:
repair znd&#21 re tarb section or on Ate bit of ddsfasn Site�m
You may use the back of this page to provide additional well site details or well
S.Number of wets constructed: I construction details. You may also attach additional pages if necessat)'.
For m lapk tWecam or nor-water supply wells ONLY with dr snare consNudiom you can
auburnoneform. SUBMITTALINSTf MOMS
9.Total well depth below land surfaer. _s4 S _M) 24a. For All Wells: Subunit this form within 30 days of completion of well
For mukfpk suds list all depths rfolff-W(c-vk- 'and 2@1001 construction to the following:
10.Static water level below top of easing: f7 (ft) Division of Water Qndny,Information Processing Unit,
If water le►rl it above casing,rose'`+" 1617 Mail Service Center,Rakfgb,NC 2769961617
It.Borehole diameter. 10 (in.) 24b.For Iniestion Wdbr. 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
awelt construction method Rotary construction to the following:
(i.e.auger,rotary,cable,direct posit,etc.)
Division of water Qwtily,Underground Injeetioftentrol P199-M-1
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a Yield(pm) MsNrod of teat Blowing-Rig 24e.For water Sanuly&Intec"wens: In addition to sending the form to
the addresses) above also submit lone copy of this form within 30 days of
13b Disinfection type: Chlonne Amount- S� 02. completion of well construction to the county health department of the county
where constructed.
r-—.....1 ws..,r,r_n..a Tlnne h—M nf Fmrimnment and Natmal Resoatces-Division of Water Quality Revised Jan.2013