GW1-2022-03986_Well Construction - GW1_20220412

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for mingle or multiple wells
1.Well Contractor Information:
Bobby W. Potts it FWATER ZOM
RM TO
nFst Rzplcot�t
Well Contractor Name M
110
NCWC 2028-A - n ft
NC Well Contractor Certification Number I&OUTER CASING >�aa•ed���L1lYSR
FROM TO DIAM. TffiC�SSI MATERML
Ferguson's Well and Pump, LLC
Company Nate 16 1NNRR G ORTQBIItTG
q FROM TO DIAM6Tlat TBKXNESS MATZMAL
L wen construction Permit M0a 1 -CSC .Iwa — R. ft i .
Lie aU applicabk weft eosbrecbon po7nits(Le.Comny,Sore,Yarimnaa etc.)
i< n ln. ,
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO I DUMELFR I Si.OT 3SIZEI UOCKNESS MATERIAL
❑Agricultural Cl cipaM%blic ft & m
00cotbarmal(Heating/Cooling Supply) [2 2esidential Water Supply(single) ft rt h
OlndustriaUCommercial OResidential Water Supply(shared) 18 GROUT
FROM TO MATERIAL F�rlPLACII111�fMETHOD3AMOtTNJ
Non-water Simply will: ft
tt:' 20 rt Concrete $ravit low
rt ft
❑Monitoring ❑Recovery
Injection We1L• n ft.
OAquifer Rocharge ❑Groundwater Remediation M SANDhGRAVEL PACK IN nolkshle)
PROM TO A MATEMAL IgMFI ACFdlIIrTl hWrHOD
OAqutifer Storage and Recovery ❑Salinity Barrier R ft
❑Aquifer Test ❑Stormwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control r
2tl DRILLIIQG LOG atla&adiBmsl aheels if
OGeuthermal(Closed Loup) ❑Traua' FROM 7Y) DFSC[t1PTtON odor dada wtUreck etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks ) n ft a
ft S "L a. S
4.Date Well(s)Completed Well
MN M ft
Sa.wen Location:�y /'- ft ft
�rJL.liegnf=4nri7 -,O,a : ft. f
Facility/Owner Name Facility M#(ik appti-M-) }'t, ft
ft M
Pkwical Address,City,aid Zip 21.REMARKS °
__:B1Ln,coM be 7 3 z/3 211538 `
County Parcel Identification No.(PIN)
Sh.Latitude and Longitude to degrees/minutes/seconds or decimal degrees:
2L Certit&atlon:
(ifwell field,amlst/long is sufficient) COAQVG
=pro
SignabWO-featfi4 Well Contractor
6.Is(are)due wells): er►m mcnt or OTmporary By elgninR dnis fonrt,I hereby certify that the—JI(s)was(were)artsJrmeted actor"MM
with 15A NCAC 02C.0100 err ISANCACI02C.0200We11 ConserwamStamdmrir aced duce a
7.Is this a repair to an existing weI DYes or Oo copy ofdds recordhas bemprovfdedto On well owner.
If dais is a repair,fill out brown well coanuctia n hf malfon mail captain he nalmie of die
repair w der#21 anemia section or on dr back of dds form 23.Site diagram or additional welldelails:
1 You may use the back of this page to provide additional well site details or well
&Number of wens constructed. constnrdion details. You may also attach additional pages if necessary.
For multiple byeenon or non-water supply wells ONLP wide de saw carsb-item You can
srebnetawform SUBACI TALDMTUCTIONS
9.Total well depth below land sarfaee: p�Q M) 242. For An Wdh: Submit this form within 30 days of completion of well
Far mzdapk wells list aU dep*s(faVrnm(emmnpk-3@200'and2WO01 construction to the following:
10.Static water keel below top of caning: 20 (R) Division of water Quay,hdorm uen Processing Unit,
Ifwarer level is above easing,use"+" 1617 Man Service Center,Raleigh,NC 276991617
11.Borehole diameter. ' U (m) 24L For Injection wens: In addition to sending the form to the address in 24a
Rota above, also subunit a copy of this form within 30 days of completion of well
a IL wen omsumcd method Rotary construction to the following:
(i.e.stag,rotary,came,direct push,etc.) r
Division of water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Ma8 Service Cent,Rakigh,NC 27691-1636
13a.Yield(gpm) 30M.&od,(.text Blowing-Rig 2&For water snoniv&Iniec. Iwdln: m addition to sending the form to
the address(es) above, also submit lone copy of this form within 30 days of
13b.Disinfection type: Chlorine Amount: : OZ. completion of well construction to the county health department of the county
where constructed.
r_—.•.,. *r.,..r,re.r,r'...e n.rortfv of F.mrimnment and Natural Rcsomoes-Division of Water Quality Revised Jan.2013