GW1-2022-03920_Well Construction - GW1_20220412

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used>or single or multiple wells
1.Well Contractor Information:
M144 . 2ANE8•
Bobby W. Potts TO DTON
wen Contractor Name fL
NCWC 2028-A ftNC Well Contractor Certification Number CASING wells OR 11NSR
dr
PROM TO DIAMLM 713CC1t NM MATERIAL
Ferguson's Well and Pump, LLC 0 fL ' 241 CS
Company Name 16 INNER G OR
PROM TO DIAMEM TIOCKNESS MATERIAL
L Well Construction Permit M R ft in.
List aQ appheablk we0 eerestrne6on pemnits(t e.Comity.Stage..Voto nm etc.) ft. IL b3
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIOW= SLOT Sr6E TM-IavPss MATERIAL
fL ft. In.
❑Agricultural ❑ lic
❑Geothamal(HeatmgCooling Supply) deatial Water Supply(single) ft ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18 GROUT --
FPMM I TO MATERIAL EbffLACFkffitTMETMD a AMOUNT
❑ tine 0 , rc 20 ft Concrete Gravity-Flow
Non-water Supply Well: ft. ft
❑Monitoring ❑Re-very
> well: ft ft.
❑Aquifer Recharge ❑Groundtwata Remediation 11 SANDAMAVEL PACK
FROM TO MA EMAL METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier R, ft
❑Aquifer Test ❑Stormwater Drainage ft
❑Experimental Technologv ❑Subsidence Control
2L DRILLING LOG attar ad"MA abeeht u
❑G eothermal(Closed Lewp) ❑Trans PROM TO DESC2UMON tedw.hardnew rotureca MK Orlin she,etc
❑Geothermal(IjeatingCoolinji Return) ❑Otha(explain under i121 Remarks) C R 2-0 fL t Ce
ft o >< �
4.Date Well(s)Completed: oZ well IDk ft it C
5s.Wen Location. V IL S`It t
fL fL
4Fa..i Name Facility II) (if applicable) ft ft
931 J -� R 6 � Q� a��s3 fL ML
Pbysical Address,City,and Zip 21.REMARKS
County Patin Identification No.(PIN)
5b.Latitude and Longitude m d tesfsecouds or decimal degreesCertification: '; F�`` `j
� 22. 1 I j
rf well field,one Win is sufficient �"�
( 0 Wong E t / L t, / - r' '.; rye.
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�S B z z�Y.? �-/ .�S/ W
sigmnrre of sit wen Mftcgr
6.Is(are)the wed(s): ermanent or ❑Temporary By sWM this forum 1 hereby ov*that due-11(s)was(were)constructed in acconlonce
wM 1SANCAC 02C.0100 or 114 NCAC 02C.0200 Well t.caamn aw Slaadm+ds and dw a
7.Is this a repair to an casting wed: ❑Yes or O copy of dda reowdha beenprv&Wto the well owner.
If ft is a repair,fell ota known well conwvcdon mat-i andeaplain the nahm of the
repair w der 921 mnarb section or on du back of tldsfom You
m use the
or additional f this
al well details:
you may use the back of this page to provide additional well site details or will
S.Number of weld constructed: I construction details. You may also attach additional pages if 11-Mal)
Fornudirpk hyechan or non-water sap*wills ONLY with dr soft aanstruefto",you can S[TBMITTAL IIVSITICTIONS
sab»atarrefomc nn ^
9.Total well depth below Land surface: �sC tl� (fL) 24a. For Ad Wells: Submit this form within 30 days of completion of well
For rmrltipk wells list aAdepda if 4bod(nn:arwk-VM'and 2W M1 construction to the following:
10.Static water level below top of casing: (ft) Divisisn of water Quality,Information Processing Unit,
If water level is above easing we +" 1617 Mad Service Center,Rahn,NC 27699-1617
It.Borehole diameter. U (m) 24b.For Inirction weds In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
1L Well eonstruction method: Rotary construction to the following: _
(i.e.auger,rotary,cable,dot per.eft.)
Division of Water Quality,unaqWam<a lajecnon central grogram,
FOR WATER SUPPLY WELLS ONLY: 16M Mad Service Center,Raleigh,NC 27699-16%
13a Yiehi(gpm) Method tit test: e.Blowing-Mg 24 Far water Stirnnly Is T. wee• Ice addition to sending the form to
the address(es) above, also submit'one copy of this form within 30 days of
Chlorine completion of well construction to the county health department of the county
13L Disinfection type: Amotmt: ' OZ• where constructed
re...e:,.,r*—rr—t of Am=imnment and Natmal Resources--Division of Water Quality Revised Jan.2013