GW1-2022-06328_Well Construction - GW1_20220705

WELL CU NSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. PottS ER MATER.ZONES TO DESCRIPTION
Well Contractor Name ft Z D &
NCWC 2028-A rt 75 ft
NC Well Contractor Certification Number - ,
IS.OUTERCASING formulfi-iscdwtM ORUNER d bk
FROM TO DIAMETER TFUCKNFSS MATERIAL
Ferguson's Well and Pump, LLC Oft & 16,. JA51
Company Name 16.INNER CASING OR .G19colhermal daxd-lou
R FROM TO DIAMETER• IMCKNEAs MATERIAL
2.Well Construction Permit#: � _fj 6 ft ft in
List all applicable well construction permits(i e.County,State,'l�anartce,etc.)• ft ft in
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE I THICKNESS I MATERIAL
ft ft in.
❑Agricultural ❑Maui blic
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft m
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT..:
❑Im ation FROM TO MATERIAL EMPLACIIIINT AMMOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft Concrete Gravity-Flow
ft ft
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL:PACK lif. b
MATTrRIAL E2�LACEt�N f
❑Aquifer Storage and Recovery []Salinity
TO M MODSalinity Barrier
❑Aquifer Test ❑Stormwater Drainage I I I '
❑Experimental Technology ❑Subsidence Control ft I & 1 ' f
20:DRILLING LOG attach additional slums if
❑Geuthtamal(Closed Loup) ❑Tracer FROM I TO DESLItE rrON color,hardness,solllrock size,etc
❑Geothermal(Heating/Cooling Return) El Other(explain under 421 Remarks) ft CD .ft
Q rt t
4.Date Wen(s)Completed: Well ID# ft /�
C
52 /Well Location:( 7-3 ft rfL
ft ft
FacilitylOwner acne Facility ID#(if applicable)
ft ft
ft ft
Physical Address,City,and Zip 21.REMARKS.
unt^av�b� -, rq
unty Parcel IdentifieationNo.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll Sell,one lat/long is sufficient) 22.Certification:
��- Si cure of ed Wel]Contracto Da
6.Is(are)the well(s): L?Yermanent or ❑Temporary
By stgmrg this form,I henrby certify that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standmdds and that a
7.Is this a repair to an existing well: ❑Yes or 2No`- copy of this record has been provi&d to the well owner.
If this is a repair,fill out known well construction bVonmation and eapla/n the nature ofthe
repair under#21 remarks section or on the back of this form 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For n adliple hgection or non-water supply wells ONLY with the sane construct an you can
subnrut are form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: (%S (ft.) 24a. For Ail Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(exmnple-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: _70 A) Division of Water Quality,Information Processing Unit,
if water level is above casing,use"+" 1617 Matz Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (ur) 24b-F-o�r Infection Wells: In addition to sending the form to the address in 24a
Rota above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Rotary construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Prggram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield m Blowing-Rig24c.For Water Suonly&Injection Wells: In addition to sending the.form to
(gP ) �� Method of test: �g
the address(es) above, also submit one copy of this form within 30 days of
-13b.Disinfection type: Chlorine Amount: S� OZ. completion of well construction to the county health department of the county
�— where constructed
Form GW-1 - North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013