GW1-2022-06332_Well Construction - GW1_20220705

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. PoLtS FROM TO I DESCRIPITON
Well Contractor Name , ft 21,0 ft
NCWC 2028-A ft ItM ft
NC Well Contractor Certification Number , I S.0 U T E R.CA SING formalti4mos cad.weas ORUMNER f
FROM TO DIAMETER THICKNESS MATERIAL
Ferguson's Well and Pump, LLC fo ft. r in. 1'�Itl
ccdwl
Company Name 16.INNER CASING OR TUMG; el -lair
4 hh FROM TO DIAMETER• THICKNESS I MATERIAL
2.Well Construction Permit#: ata I - V U q I ft ft izc
List all applicable well construction penmis(1 e.County,State,I/w7arce,etc.)'
ft ft in.
3.Well Use(check well use): 17,SCREEN
Water Supply Well: FROM TO DIAMETER I SLOT SIZE I nUMMESS I MATERIAL
❑Agricultural ❑M�cfpal/public ft ft in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft to
❑Industrial/Commercial ❑Residential Water Supply(shared) 11 GROUT.
FROM TO MATERIAL EMPLACEMFNC MMOD 8 AMOUNT
❑1ni ation
Non-Water Supply Well: ft 20 Concrete Gravity-Flow
ft. ft
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK, e
FROM TO MATERIAL EMPLACE24ENT14IIs-1TROD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft`
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DREUJ NI:LOG(att2di'additional abeeft if
❑Geuthermal(Closed Luup) ❑Tracer FROM To- I)MCMIKION color,hard.ess,solln'octt d2e,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) ft. ( .ft
� S
4.Date Well(s)Completed: Well ID# ft 'ft
45--f` D f` © C
SVY'aa..Well Location: ft ft
4f Y'1 A ahe.l ct- ft ft
Facility er Name Facility ID#(if applicable) ft ft
A!5 (hi55ionaru Li4ri,.e tg_L-e_G�ei- a.e 74a ft ft n (►22
Physical Address,City,and Zip
�^l R / l ZL REMARKS
�e -7 oU [) I I�A / �.��:vi '�1 ��is ... w';7 Unit
County Parcel Identification No.(PIN) ur nV J 1
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
5SO�V �7, -,W22 'I XA 71AA� SignatumofC fed 1 .tractor to
6.Is(anti)the well(s): L�Permanent or ❑Temporary By sy this form,I herby certify that the well(s)was(were)constructed in accordmrce
with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 990 copy of this record has been proviekd to the well owner.
If this is a repair,fill out brown well construction information and explain the nature of the
repair under#21 remarks section or on the back of Lhisform 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 multiple iryectton or non-water supply wells ONLY with the saw cmtsbudion,you can
submit oneform . SUBMITTAL INSTUCTTONS
9.Total well depth below land surface: 362's (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if df erent(example-3Qa 200'and 2 rQ100') construction to the following:
10.Static water level below top of casing: 20 (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 241b.For Iniection Weill: 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: ry construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground InjectiowControl Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-16M
13a.Yield(gpm) 1910 Method of test: Blowing-Rig 24c.For Water Saw&&Injection Wells: In addition to sending the form to
the address(es) above, also submit one 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 Fonstructed.
Form G W-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013