GW1-2022-03957_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:
it WONES
Bobby W. Potts PR METER TODZSCRIPTI0N
ft ft.
Well eonuacwrName
i
NCWC 2028-A ; n ft
NC Well Contractor Certification Number 15.OUTER CASING asutft�sed we11a OR LINER bk
FROM I TO DTAMETFR THICKNESS I MATERIAL
Ferguson's Well and Pump, LLC ft- 1,7 2 S ;R 2
Company Name I&INNER CASING OR TU=G foodierinal doted
PROM TO DL1ACM THICKNM MATERIAL
L Wen construction Permit#: a 616 61 $ 9 3 G ft ft
List all applieabk well constrwilon perntts(Le.County,State,Yatdare,etc.)
ft ft in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE TffiCKNESS MATERIAL
ft ft is
❑Agricultural ❑ ctpal/Public
❑Geothermal(Heating/Cooling supply) dResidential water supply(Single) ft. ft
❑Industrial/Commercial ❑Residential Water Supply(shared) "L GROUT FROM TO MATERIAL EMPLACEMENT b=OD a AMOUNT
OIrrigation 0 ft 20 ft Concrete Gravity-Flow
Non-Water Supply Well:
ft. ft
❑lvlonitoring ❑Recovery
Injection Well: rt ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVSL PACK fir xoticidile)
FROM TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft.
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology OSubsidence Control 2a DRILLING LOG attach additional sheets H
❑Geuthermal(Closed Loup) ❑Tracer FROM TO DFSLVj ION rdor hardn sdM*clt OW,Vain dze,etc
❑Geothermal(Heating/Cooling Rearm) ❑Other(explain under 421 Remarks) & 60 ft C a
ft ft. tr
4.Date Well(s)Completed:% �! Wen 1D# G
SIL-Ween location: R ft C
_)K1Me-c-L. =I�� ft ft
Facility/Owner Name Facility ID#(if applicable) f ft .•. a M
G .•
K ft
Physical
�Address,
�City,and Zip APR 12
21.REMARKS
Cqty Parcel Identification No.(PIN) 6rw .e
� an'l
trim i
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degees: 2L Ce n:
(if well field,one laf/long is sufficient)
Sigffiture o21:
6.Is(are)dire weII(a): lZPermaneat or ❑Tampotary B si- _ m.1 hereby orrVy that dw well(s)was(were)corsyrtCted in accom(Mce
widt 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Consirwil n Stadm&and that a
7.Is this a repair to an esisting wcL- ❑Yes or 0No copy of fhtt rieonrd has been p►ovtded to the well owner.
ifthis is a repatr,fill out knmm well corsvuctm h#bnnation and erplwn the nature ofthe
repair wm*r#21 r mmla section or on the back of lUsform You
Site diagram oradditional
k-o f o s agewel to provide
/ You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For nv&pk b#ecu m or nor-water supply wells ONLY with the smne catsbvetian,you cure SUBMITTAL E%TUCTIONS
subni t oeeform
9.Total well depth below had snrfsce: 5�5� —(ft) 24a. For All Wells: Submit this form within 30 days of completion of well
Far—Ihpk wells list all depths if do~' (ermmpla 3®200'and 2@1001 construction to the following:
10.Static water level below top of casing: S�7 (ft) Division of Water Quality,Information Proccaft Unit,
If water level is above casing,use,"l+" 1617 Mall Service Curter,Ralcigth,NC 27699-1617
It.Borehole diameter. 1 U 010 24b.For Injection WeOs: 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
IL Well constraetion method: Rotary construction to the foIIcaing:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 M Service Mad Center,Raleigh,NC 27699-1636
13a Yield(gpm) J - Mctihod of teat Blowing-Rig 24e.For Water sunnly&Inieetionf Willa In addition to sending the form to
the addresses) above, also submit I one copy of this form within 30 days of
136 Disinfection Chlorine Amotmt oz. completion of well construction to the county health department of the county
type where constructed
lr—u r,..i;-rrnmrt—t of Am imnment and Natural Resources—Division of Water Quality Revised Jan.2013