GW1-2022-03980_Well Construction - GW1_20220412

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This fixm can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES
Bobby W. Potts FROM TO I DUCRSTION
Well Contractor Name n
NCWC 2028-A rz tt
NC Well Contractor Certification Number 15'OUTER CASING flarumilkased wdh OR LINiSR
FROM TO DIAMETER THICKNESS MATFRL_L
Ferguson's Well and Pump, LLC R. �• ,l C g z�
Company Name 16 G ORTIJBIl►iG dosed
ZD Z l FROM To DIAMETER THICKNESS MArrrttwL
L wen construction Permit a: " 6�.c�// R ft
List aU applicabk weft cawtrwfion perWis(Le.Comfy,Stole,.Varlmice,i9c.)
R tt ' in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: mom I To I DI mmat I SLOT um I Tfficgnss I MATERIAL
ft. ft In.
❑Agricultural ❑Munich . lic
❑Geothermal(Heating/Cooling supply) BgQential water Supply(single) ft ft
hL
❑IndustriWCommemial ❑Residential Water Supply(shaded) 18.GROUT
PRAM TO MATERIAL McLACEMINTMETHODaAMOUNT
chrijqation 0 ft 20 ft Concrete Gravity-Flow
Non-water Supply wen: ft ft
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 11 SAND/GRAVEL PACK
FROM TO I FMPLACEbtM MELHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft
❑Aquifer Test ❑Stormwater age S, ft
❑Experimental Technology ❑Subsidence Control Z0,DRILLING;AG attach addltlaohd sheets if
❑Geuthermal(Closed Loup) ❑Trans FROM I TO DFSLMMON rater earth M-k etc
❑Geothermal(Heating/Cooling Return) ❑Otter(explain under 421 Remarks) 0 ft Gt
^ ft n S C{/f
4.Date Well(s)Completed: �� Well mm ft ft 00
C
r9
Sit.Well Location: ft 1_11 f t t
.1b'dinel e-7..0� ft ft
Facility/Owner Name Facility ID#(if applicable) {t ft
Physical Address,City,and Zip 21.REMARKS
-9 79 a q 5-6,4 A
County ParcelIdentifica' nNo.(PIN)
5b.Latitude and Lontitade in degmes/minotes/seconds or decimal des: 2L CertiScadon: Sj
� ti �ts
(if well field,one lat/long is sufficient)
3 S°`//•'' � S 7/( Div Slz�yS/ta 1, 7 32L w
�" Sigmwm of ' ed Well Coo
6.Is(are)the wells): H'gcrnsaneat or ❑Temporary gy stgrmg dr's form,1 hereby ce?*that the weU(s)was(were)conslractei rn accordance
with 15A NCAC 02C.0100 or IJANCAC 02C.0200 Well Conwt am Stodontfs and that a
7.Is this a repair to an existing wen: L1Yes or O o copy afdas rr cord has been provi&d to dw well owner.
If tics is a repair fill out Ifvfawn well easstruchart v#b"nmlion and eaplavt the rttrtrne of the
repair under il21 ren z4a section or on the back 4'thts form 23.Site diagram or additional wen'details:
You may use the back of this page to provide additional well site details or well
S.Number of webs constructed: construction details. You may also attach additional pages if necessar}'.
For rmdlipie i4ecam or norr-water supply wells ONLY mth dw sane consvuedo e,you can ��M�INSTUt TIONS
submit aneJonn
9.Total well depth below land surface:3 d (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For—,bpk welts list aU depths tJ'4bent(—plc-3@200'and2W001 construction to the following: j
�!,10.Static water level below top of casing: 0�) Division of Water Quality,Information Processing Unit,
(./
If water level is above coring,use.+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Bordwle diameter. 10 (in.) 24b.For Inieetlon Wells: 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
12.Well construction method Rotary construction to the fulluaing: i
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Quality,Undetgroand Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
I
13a Yield(gpm) Method of teat Blowing-Rig 24e.For Water S�nly&bhiectio Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
Chlorine yA OZ. completion of well construction totthe county health department of the county
13b.Disinfection type: Amount: where constructed.
*r_u re.,.r.a r._rm f of Rmrimnment and Natural Resources—Division of Water Quality Revised Jan.2013