GW1-2022-03955_Well Construction - GW1_20220412

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts 14*. ZONES
FROM TO DESCRIPTION
Well Contractor Name ft /)v
ft
NCWC 2028-A ft ft
` 15.OUTER CASING or maltia�sed webs OR LIlYER d
NC Well Contractor Certification Number e
FROM TO DIAMETER TtIICIi�IETS MATERIAL
Ferguson's Well and Pump, LLC Irk s RR 2-
Company Name 16.INNER CASING OR TUBING. dosed
A ^� FROM TO DIAMETER 1WCISNFM MATERIAL
2.Well Construction Permit#: Nr.M- ft ft in
List all applicable well construction pennits(i.e.County,State,Ilarimrce,etc.)
ft ft
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FRO TO DIAMETER SLOT SIZE THICK MATERIAL
ft ft. in
❑Agricultural ❑Munici lic
❑Geothermal(Heati4Cooling Supply) esidential Water Supply(single) it ft in;
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Nonn--Waate
❑ ter Supply Well: 0 ft 20 ft Concrete Gravity-Flow
ft ft
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK fir awlicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier mom TO MATERIAL 1LACEMEIvr1ALrtHOD
ft ft
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control 2LL DRILLING LIH;<.attar atldutiutoal Abeets if 4
❑Geothtamal(Clused Loup) ❑Traua FROM TO DERX]PTION color,hardness,sollfreclt Lyfw,omin dze,etc
❑Geothermal(HeatingACoofing Return) ❑Other(explain under 421 Remarks) 6 ft. 5 ft .
77 ft ft
4.Date Well(s)Completed: /Z Ojatwen ID#
fc � rt f'0
Sa.Well Location: A
tt ft !n. L
r 1( L(OU ft ft ,.. 4
Facility%Owner Namc Facility ID#(if applicable) ft ft n f-
U. ci 'APR 12 14AriC 0..J- QAA 16tt•1 fs 7 � �f1_ rt ft
Physical AdMss,City,and Zip ZL REMARKS 4..� .
G1U tiJ[bcj 111:7- 74-(lino .rp. "t 4occ—ss'-u Ui\
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certifa:ado
(if well field,one lat/long is sufficient)
/2 g/ oZZ464!r:
W -3/
Signature of well to re
6.Is(are)the well(s): Ofrl manent or ❑Temporary
By stgrdng thrts form,I hereby certify that the weA(s)was(were)corWnacted in accordance
with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Wdl Constnrction Standmds and that a
7.Is this a repair to an existing well: ❑Yes or 2KO copy of this record has been provi&d to dw well owner.
If this is a repair,full out brown well construction irrfor n ftir and explain the nature of the
repair under#21 ranarAs section or on due badr of dw 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 multiple i Section or non-water supply wells ONLY with the same construedom you can
sub»rit orreform SUBMITTAL INSTUCTIONS
9.Total well depth below land surface.:�� (a) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depds ifd�'erent(example-3Q200'a1n/d�2@I00') construction to the following:
10.Static water level below top of casing: �!/// A) Division of Water Quality,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: _ (in.) 24b.For Infection Wells: In addition to s.d,.g th otm to the address in 24.
Rota above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ry construction to the foHovdng:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injectio*Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
c. or Water narl I y& nieetion4ells: In addition to sending th
13a.Yield(gpm) /Z. Blowing-Rig Method of test: 24 F Wt S � e form to
the address(es) above, also submit Jobe copy of this form within 30 days of
13b.Disinfection type: Chloride Amount: oZ. completion of well construction to the county health department of the county
where constructed.
Form @W-1 - North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013