GW1-2022-03984_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 FMM DESCFdMON
Well Contractor Name O' f`
NCWC 2028-A " ft
NC well Connector Certification Number 15.OUTI R CASIPtCs ms" OR INNER
PROM TO D7AMLTPR TffifSQ1PSS MATERIAL
Ferguson's Well and Pump, LLC ft. 11 ft i2 1- � !RS AIC 7
Company Name - ML INNER CASING ORTUBM
a ba t - d ft. ft.PROM . DLtl MTnt T,D�t» MATERIAL
IWell Construction Permit# in.
List aft applicable weft ee owdor perimis(ie.Coratry,State,V&*WA etc.). ft ft is
3.Well Use(eheclt well use): 17.SCREEN
Water Supply Wes: mom I DIAMETER SI or S= tmctnvEss MATERIAL
ft ft
pA�culWra► []Msmi ' lie
[]Geothhamal(Heating/Cooling Supply)
tial Water Supply(single) O• ft is
Mridustrial/Commercial []Residential Water Supply(shared) I&GROUT
FRAM TO MATERIAL E dFLACEBUMM MMOD at AMOUNT
0krization 01 ft.1 20 ft Concrete r ravttN- Iow
Non-water Supply Wen: ft ft
[]Monitoring OReei very M ft
bdedion WeIL•
[]Aquifer Rooharge []Groundwater Reme ration 19.SANDlGItAVSI.PACK
PROM TO gOD
OAquifer Storage and Recovery ❑Salinity Barrier ft• ft
[]Aquifer Test O Stormwater Drainage ft. ft
[]Experimental Technology OS»bsidence Control
2L DRIi.L11�iG LOG attash addhiaw sbeeb W
OGeuthesmal(Closed Loup) []Tracts FROM To DY�krd*rUdv eardn saunacte .-
[]Geothermal(Hea oo Retum []Other(explain undo#21 Remarks tL ft &V
ft ft Q
4.Date Well(s)Completedi �/ Well ID# ft ft
sa wen Location: IL ft GIJ�
ply la�ef��uil,l fL ft
Facility/owner Name Facility M#(if applicable) R ft
153 feJ Linn (J'iye_ Fan:".CL1, 98-73 a R ft
Physical Address,City,and lip 21.REMARKS
07f
County Panel Idettifieation No.(PIN) APR 12
5b.Latitude and Longitude in degreea/minutedseconds or decimal devces: 2L CertiBadon:
(if well field,we Wong is sufficient) - Sr i 0 r e p l l�il P �C
s' eel well con
6.Is(are)the well(,): ernraneat or OTem orary By sWmtg dw fob I hereby aw6 dhat do weft(s)was(were)—*--ad in accordance
with 15ANCAC 02C.0100 or 15ANCAC 02C.0200 Well ConsOw imStandan*mud slat a
7.Is this a repair to an existing wen: OYes or CCdRo copy of ft reoodhas bean provided to die well owner.
if dds is a repay,fill out blown well construction b#bm ation and usplafn due nature ofdw 23.Site diagram or additional well details:
repair roller 421 ren rb section or on due back of deisfonn You may use the back of this page;to provide additional well site details or well
L Number of welts constructed: construction details. You may also attach additional pages if necessary'.
For narLiple b9oc6an or nor-water soppy wells ONLY wuh the amuse eartsb+v�ah you can SUBMITTAL INSTUCTTONS
submit preform
!/ S (tik) 24a. For All Wells: Submit this!form within 30 days of completion of well
9.Total well depth below land sasses~
For muldpk wells list all depdts if aB,fenmt(esmr e-3@200'mad 2@1001 construction to the following:
10.Static water keel below top of asing: /� go %dolen of Water Quality,Information Processing UDA
If water level is above casing,use
'"l+" 1617 Mall Service Center,Raker,NC 27699-1617
it.Borehole diameter. 1 U (m.) 24b.For Iniectien weIIr. In addition to sending the form to the address in 24a
above, also submit a copy of this 1fonm witbin 30 day-,of completion of well
12.well eanhmaetiion method: Rotary construction to the following:
(Le.auger,rotary,cabl4 direct push,ere.) Division of Water Quality,Underground InjectI&Control Ptegram,
1636 Man ServiceCurter,Robi*,NC 276WI636
FOR WATER SUPPLY WELLS ONLY:
13a Yield m Blowing-Rig 24-For waterSmnh+&Inlec"Welk: In addition to sending the form to
(SP ) Melhodof teat; the address(es) above, also mkOk One copy of this form within 30 days of
Chlorine �® OZ, completion of well construction to the county health department of the county
13L Dlsintection type: Amount: where constructed
i
Revised Jan.2013
M h r•"...h:..e TI—rh—M of A,mimnn Quality
rent and Natural Resources-Division of Water ity