GW1-2022-03990_Well Construction - GW1_20220412

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This farm can be used for side or multiple wells
1.Well Contractor Information:
Bobby W. Potts 1 WATSItztO DESOMMON
Well Contractor Name
tz ct
NCWC 2028-A f`
Or
NC Well Contractor Catificauon Number 15. E ll�tC- a MOMFROM TO DU1�1'FR TffiC6a�SS MATERTAL
Ferguson's Well and Pump, LLC R & a is Z/ ., - C Q
Company Namc 1 1NAiER G OR
�� (o 15 F� TO D1A11�'I'EA � MArsIaAl.
2.wan Coustruetiou Pettoit#: 6 I _ ft List aft applicable wfl caWiuodwe permais P.Comriy,�,variar�A etc.) rc is
ft ft in.
3.Well Use(check well use): 17.SCREEN
MATERIAL
Water Supply wen: FROM To DI ASM St.OT Sr6E TffiC[Qrl�S
ft ft.
❑Agricultural ❑Muni ' lic
hL
eothermal(Heat.&Cooling Supply) esidemtial water Supply(siugle) n rt
❑rr
❑Industriallcommercial ❑Residential Water Supply(shared) '
PROM TO MATERIAL EAffLACDaNTMnMD&AMOUNT
ChriAahon 0 !z 20 ft Concrete Gravity-Flow
Non-water Supply well: ft re
❑Monitoring ❑R—vtsy ft ft
hoction Well:
❑Aquifer Recharge ❑Groundwater Remediation 19 SAND/GRAVBL PACK p�ffI ACF11RTrr METaoD
FROM TO MA r
❑Aquifer Storage and Recovery ❑&didty Barrier g g•
❑Aquifer Test ❑Stormwater D singe ft ft
❑Experimental Technology ❑Subsidemce Control X DPJMMG LflG agadt adeliaerl<beeta it
❑C=thtm2W(Closed Loup) ❑Tracer FROM TO DEscRilMltxv Color,trade ad;M
OGoothamal(HeatingCooling Return) ❑Other,(explain under 1121 Remarks) n ft k
ft —ft. 6l
a.Hate Well(s)Completed: well 11 _n
/ 0
Sa.WeR Location IL ft C-
0 v tt ft
acility/Owner Name Facility ID#(if applicable) R
ft f
Physical Address,City, zip Z.REMARKS
County Pareel Identification No.(P ) rx i,� �� rE OCES ;'':U LOT
5b.I.admde and Longltude in degeer/aalnntea/seconds or decimal degrees: 22.Cerdficadon:
(ifwell field,one Wong is sufficient)
s w
6.b(are)the wen(s): ert>mneat or ❑Temporary By stgW d-fornt.I hereby orro drat dam-ji(s)was(were)oatsdneted in aceor&—
wUh ISA NCAC 02C.0100 ar 15A NCAC 02C.0200 Weil ComWwlion Stmidx%*and done a
7.Is this a repair to an e:dsdng well: ❑Yes or c1'41dds reamedhas bearP►avtkd to ehe well owner.
Ifdds is a repair,fill ore brown well oannrIC0011 uybrnn M turd 6WId t die norroie afcite
repair wader#21 remarks mefion or on the bent of dalsfare. You
m diagram or aaddit this
sad well o Foy:
L you may use the:back of this page to provide additional well site details or well
8 Number of weEs constructed: construction details. You may also attach additional pages if necessary.
For mddpk hg donor norm-water srtpply wells ONLY wide cis now 7xpavt4a4 YOU amr SUBPA TZ,AL INSTIICTIONS
svbmiromeform
9.Total well depth below land surface. M.) 24a. For All Willa: Submit this'form within 30 days of completion of well
For md4pk wells lust all depths if 4irent(mwpk 00'and 2®1001 construction to the following:
ty,Informtiion Processing Unit,
10.sortie water keel below top of enaiog: (ft) Division of water QoaH
if water level is above eaft use"+„ 1617 Man Service Curter,Rabdgh,NC 27699-1617
it.Borehole diameter. (m) 24b For Insertion W�a: In addition to sending the form to the address is 24a
Rotary above, also submit a copy of this;form within 30 del}'s of complexion of well
1L Will rnnsttrucdon method construction to the following_ a
(i.e.eager,rotas,cable,direct push,etc.) Division of Water Quality,Underground Injection Cont ml Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Man Service Centex,Rakl&,NC 276WI636
Blowing-Rig zae For water Semnly Ibieetia won.• In addition to sending the farm to
132.Yield(gpm) M�?f tee the addresses) above, also submit"ore copy of this farm within 30 days of
13b.Diainfeetiontype: Chlorine Amount. J oz. �r��n cOf a eonattttotion to the county health department of the county
*r.. u r. ttnu r t—rt v,N of F.m i nnment and Natmal Rosoumes—Division of Water Quality Revised Jan.2013