GW1-2022-03981_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:
1444L ZONES •
Bobby W. Potts FROM TO DESCM TION
Well Contractor Na ft ft.me
NCWC 2028-A " f`
NC Well Contractor Certification Number OUTER G saoifless>ed well°a L
FROM To DrAM� Tffic�vass I MATERIAL
Ferguson's Well and Pump, LLC R 2l1 ku Wt C
Company Name ME INNER CASING OR TRBM
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FROM I TO I DIAMET1Sn
IWen construction Perm ftit#: (/ (•'D(/ a`I m MATERIAL
List aAappheabk weg eaw&wfioh perndts(te.Coady,$tote,Yarioneg eta) & ft
3.Well Use(chock well use): 17.SCREEN
Water Supply Wen: PROM To I DIAM9= I SLOT sreE Ttuciavlss I MATERIAL
ft ft fn
❑Agricultural ❑ �pal/Riblic
❑Geothermal(Heating/Coolrng Supply) 6lfilesideatial Water Supply(single) N• ft
F
❑lndustrial/Commercial ❑Residential Water Supply(shared) GROUT =
FROM I TO MATl12tAL r F16LACIINFN'1'METHOD 3 AM011td!'
01mixation 0 - ft 20 ft Concrete praviiy-Flow
Non-water Supply Well: ft ft
❑Monitoring ❑Recoverry
hj�u q,� n ft
❑Aquifer Recharge ❑Groundwater Remediation 1%SAND/GRAVEL PACK
FROM TO MATERIAL METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier fL ft
❑Aquifer Test ❑Stormwater Drainage R tt
❑Experimental Technology ❑Subsidence Control r
Z0.DRILI.II�IG LOG atta&adrHBanal sheets fd'
❑Geuthermal(Closed Luup) ❑Tracer FROM I TO DEKSUin'[tkt ftobr hardness,$WINN, Wall d2e,etc
❑Geothermal(Hea .gg Return) ❑Other( under#21 Remarks) O n tt
14 ft. n Al
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4.Date Well(s)Completed:) aZ well m# ft. en fL
52.Well Location: ej ft b S fl. W
P-hod & ft
Facility Facility M#(if applicable) ft ft
c ion Ike � � 2yg tti ft. Fy w
Physical Address,City.and Zip IL RRMARIM ( •
county Parcel IdeffiticationNo.(PIN)
56.Latiprde and Longitude in degr eex/ntinntealsecends or deeilmal degrees: 22.C rtiflcadon:
(if'well Sell,one laillong is sufficient)
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Signature of ed Well Contractor
6.Is(are)the well(s): enwaaeat or ❑Tmporary By jwww this farm,1 hereby terry that the w o(s)was(+m)cornrsraead in accordanoe
with 154 NCAC 02C.0100 or 15ANCAC 02C.0200 Well Constrwfim&ambn*arrddw a
7.b this a repair to an esisting wen: ❑Yes or l copy of this necordhaa beat pro*W to dte sadl owner.
lfdds is c repair,fdl ord known weII construction 60matiorr turd eapkd►e the rmhm of the
repair miner#21 nasofa section or on die bock of ddsform 23.Site diagram or additional wei 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 nil k*k tgecam or non-vatersappy webs ONLY with dw same co urnteriae,you cm 3UBM11TAL DMMCTIONS
srrbrhdt orhefornc
9.Total well depth below hind sarfaee: (ft.) 24a For All well: Submit this form within 30 days of completion of A-11
Farnadliple wells list agdepdts tfAftront(a-Vk-3®200'and 2W 000 construction to the following:
10.Static water level below top of caning: 119 (ft.) M*itn of Hatter Qa*,Inforitation Processing Unit,
1Jwater/eu e/k aboNe casing,rue + 1617 Man Service Center,Ral igit,NC 27699 1617
11.Borehole diameter. I U (m) 24b.For Infection wells In addition to sending the form to the address is 24a
Rota above, also submit a copy of this''form within 30 days of completion of well
12.Well construction nw&od Rotary construction to the fbHoaing. _
(i.e.anger,rote y,table,direct per.cu.) Division of Water Qaatity,Undergrentd Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 MaB Service Center,ftklgh,NC 27699-1636
13a Yield m ®: Meld oitest: Blowing-Rig 24e.For Haber suoaly&Ltiectise wens• rn addition to sending the form to
iSP ) the address(es) above, also submit one copy of this form within 30 days of
Chlorine JD OZ. completion of well construction to the county health department of the county
13b.Disinfection type: Amount. where constructed.
*r....t,r•,..a:.,e n.,,n.rn,.m ofR,nrimnrnent and Natural Resources-Division of Water Quality
Revised Jan.2013
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