GW1-2022-06333_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. Potts MATER T2ANES DESQ2TPITON
Well ContractorNamc ", fk 0 ft
NCWC 2028-A ft �// ft
NC Well Contractor Certification Number I&OUTER CASING frrtmniti .Wells OR LINER fif M4Sbk
FROM I TO DIAMETER THICKNESS MATERIAL
Ferguson's Well and Pump, LLC & ft- y'1' w1.56 E
Company Name 16.INNER G OR TUBIlV . dosed-too
A FROM TO I DIAMETER THICKNESS I MATERIAL
2-Well Construction Permit#: 2 0 Z 2- ft & in
List all applicable well construction peanuts 0.e.County,State,Ywimrce,'etc.) fL ft in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER Slur SIZE I THICKNESS I MATERL41,
ft ft in.
❑Agricultural =esidential
pal/Public
❑Geothermal(Heating/Cooling Supply) Water Supply(single) ft ft in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 11L GROUT. .
FROM TO a MATERIAL Ml 1PLACEMENT METHOD dr AMOUNT
❑hri aaon 0 ft 20 fL Concrete Gravity-Flow
Non-Water.Supply Well:
❑Monitoring ❑Recovery ft ft
Injection Well: £t ft
❑Aquifer Recharge El Groundwater Remediation 19.SAND/GRAVEL PACK,Iff avalicabic)
❑Aquifer Storage and Recovery ❑Salimty Barrier &FROM To ff MATERIAL EMPLACEMIISfMMOD
r
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft ft i
2a DRILLING LOG:atta h:wI&tiA if
❑Geothermal(Closed Loup) ❑Tracer FROM I To DESt.'ItIMON color hardness,soilhocit d= etc
❑Geothermal(Heatin Coohn Returnn❑Other(explain under#21 Remarks) ft .O .ft A 1
4.Date Well(s)Completed:
Well ID# U tt ft SQ
ft ft
Sa Well Location:
139 IL Sft
ft ft _ ti . . am
Faci r `% er:Name Facility ID#(if applicable)
�/ ft ft .-
L�� i ,�K.Y 2022
ft. ft
Physical Address,City,and Zip
2LREMARn _o-n ��: ;
�9 _� i x..
� rn
C.ounn Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lavlong is sufficient) 22.Cerlifieation-
35030 (WW2 tr N 92.vl/3r V 3,!F/7l, tt W
Signattue of C ed Well Contractor arc
6.Is(are)the well(s): 2'Permanent or ❑Temporary
By signing this form I hereby certify that the weA(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Constriction Standards and that a
7.Is this a repair to an existing well: ❑Yes or Ar. copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction Wor»ration and explain the nature of the
repair under#21 remarks section or on the back of thisform 23.She diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells,constructed: construction details, You may also attach additional pages if necessary.
For rrurltiple injection or nor-water supply wells ONLY with the same eonshuctioM you can
submit oneforns. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 1615 0L) 24a. For All Wells: Submit this form within 30 days of completion of well
For inuinple wells list all depths if drffermt(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft) Division of Water Quality,Information Processing Unit,
If water level is above caring,use"+" 1617 Mao Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: _(in.) 24b.For Iniection 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 metho Rotary d: construction to the follouing:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injectiqj�Control PcDgram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-16M
13a.Yield(gpm) $ Method of test. Blowing-Rig 24c.For Water Suonly&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 136.Disinfection days of
type: Amount. S 0 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