GW1-2022-03982_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 iF�4'FE I TOONBB DESCR1p M
Wall Contractor Nam R �`
NCWC 2028-A ft- 1-7,60
f`
NC Well Contractor Certification Number 11 O TPER��r' wed R IJNSR
FROM TO DIAI�.TFR iffiCIiNPSS MATERL41,
Ferguson's Well and Pump, LLC a."as, p(Ir-5PA41
Company Name 141NNEMR CASING OR TQBMG
/ FROM TO DMN TEIt TIDCKKM MATERIAL
L Well Construction Pernut M 2 0 2- f (,��� ll^-- ft it. is
ListaA applicable weft eantrwilonpernatsAe.CawdyStatr,Yarimr,,efrl ft. it. m
3.Well Use(check well ode): 17.SCREEN
Water Supply Wen. FROM TO I DM ARM I sI Orr SIZE mummes IMATERIAL
ft fL �
❑Agricultura ❑M UP
l /emicipaublic
eo❑Gthermal(HeatinpCooling supply) 0<1;tial water supply(single) fc ft in
❑IndustriaUCommereial OResidential Water Supply(6arbd) '•GROUT =
FROM TO MATERIAL MOLACEbffiel'1 IUMD A AMOUNT
OIrrigation 0 . ft 20 ft Concrete f;raVity-Flow
Non-Water Supply Well: ft ft
❑Monitoring ❑Recovery
Injection Weu: n r`
❑Aquifer Recharge ❑Groundwater Remediation 19 SAMV RtAVEL PACK
FROM TO MATB<r7AL 104PLAC'EMSMAMOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. it
❑Aquifer Test ❑Stormwater Drainage g• ft
❑Experimental Technology ❑Subsidence Control DRII1.II�tG Ltd auade rd�ts it r
❑Gcuthenmal(Closet Loop) ❑Trau r MUM TO DFS(3UFn0N color h2rdp0g6 eoturwa �
❑Geothermal(HeahngCooling Return) ❑Other( lam under#21 Remarks nZQ ft t
ft: it
4.Date Well(s)Completed: S Well M#
ft A ft t
Ss.Well Location: ft 5 ft
�—
�R t t R ft
Facility/Owner Name Facility ID#(if applicable) ft, ft
Lrl-(-ec 1Er1 a���A fL ft _R
Pl vsical Address,City,and Zip 21.REMARKS
f.n�i�m bt i 1 gaL4Ls d ell„
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.CerfifltYti P�'�i' '��iA Yt����.+,`•�+'����3
(if Well field,ewe latAong is sufficient)
'�Q�03A W Z2
s- • ea w can j
6.Is(are)the wells): ermanent or ❑Temporary By sfgwg des faint,1 hereby on*dtar the weU(s)was(wen)cast&wscd or aeaordsom
with 114 NCAC 01C.0100 or 114 NCAC 02C.0100 Well Cons"Clim Staadar&and drat a
7.Is this a repair to an e3dsdng weft: ❑Yes. or Mfo copy afdds record has been pmw&d to dta weR ow►,er.
If des is a repair,fdl osa brawn well eoresbnctian it 0"N fim and explain die mime ofdr
repair under#21,,amid swam or at die back of des form. 23.Site disgman or additional well details:
/ You may use the back of this page to provide additional well site details or well
L Nmnber of wets constructed: / construction details. You may also attach additional pages if necessary'
For nnrlapte injection or nor-wafersappiy wdls ONLY w1*dr same ca sfteftelk you can SUBMITTAL
INSMMONS
ssrbnat one farm
9.Total well depth below land surface: 36 S (it.) 242. For AB m Wells: Submit this!for within 30 days of completion of well
For nwMpk wells list aU depths ifAftriert(esaapk-.?WM'and 1Q1001 construction to the following:
Division of Water Qadity,Information Proeeyaing Unit,
10.Static water level below top of casing 7// ( ) NC 276994617
If water level is above ca ft use"+" 1617 Mall Service Center,Ralalgb,
11.Borehole diameter. (m) 24b.For Iniecdon Weirs: In addition to sending the form to the address in 24a
Rotary above, also submit a copy of this iform within 30 days of completion of well
11 Wen construction method ry construction to the fallowing: _
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control PeTogram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Centex,Raleigh,NC 27699-1636
13a Yield(Spin) Method of teat Blowing-Pig 24e.For Water Suonly&Modica Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Diaiiafeetiontype: Chlorine J Amount- �J'g 0Z. co ltt Mien to d= county bealth depar =t of the county
uy. %.re..,n—t1.,n" .rat of F.mrimnment and Natural Resourm—Division of Water Quality Revised Jan.2013