GW1-2022-06334_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 14..WAkXER -
FROM TO DESCRWTION
Well Contractor Nam. ft ft
NCWC 2028-A ft ro ft
NC Well Contractor Certification Number IS.OUTER CASING(for lnnliteasW.wdls ORLIN
Ferguson's Well and Pump, LLC ER if bk
FROM TO DIAMETER 1HIrunmee MATERIAL
ro ; 2
Company Name 16.INNER ING OR TUBING: dosed m
7 O O FROM TO DIAMETER nucRNESS MATERIAL
2.Well Construction Permit#: L 'ft ft in.
List all applicable well construction permits(x'e.Cotmty,State,wiwice,etc.)'
ft ft in
3.Well Use(check well use): 17.SCREEN
W!!ePsupply Wen: FROM TO DIAMEi M SLOT SIZE THICKNESS I MATERLAL
gAglicultural ❑ ipal/Public ft ft in
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft hL +
❑Industrial/Commercial ❑Residential Water Supply(shared) 18..GROUT
FROM TO a MATERW, EMPLACEMEISTMETHOD&AMOUNT
Non-Water Supply Well: 0 Gravity-Flow
20 ft ConcreteFlow
❑Monitoring ❑Recovery ft ft
Injection Well: ft. &
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVEL PACK e
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. TO_ MATERIAL EMPLACEMENT METHOD
ft.
❑Aquifer Test ❑Stormwater Drainage
ft ft
❑Experimental Technology ❑Subsidence Control i P
20:DRILLING LOG:attadi additional sheets if
❑Geutheamal(Closed Luup) ❑Traccr FROM TO DEStdTWN color,hardy sollfrock she,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) bi:fE
( � ft ft. ft a.
4.Date Well(s)Completed:Wd_7A-1,Well ID# Q ft ft
mo T
Sa Well Location:
IL
A T 11 1 n
rreLyrll L /1 Q ft ft �.t ':-Tr' 1 �''•t!—1
Fazilityl6vner.dam, Facility IB#(if applicable) n ft
.3
2 I Q22�r « 70q ft ft
Physical Address,City,and Zip -
2L REMARKS
unL'nm�e �629 3fC' C�153
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/rdnutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one W/long is sufficient)
0 A� 0 *31 '57�?j 7311"' w J,ZZ
Si o 'fled eo for ��
ex-
6.Is(are)the well(s): CdPermanent or ❑Temporary By,rim this forn;I fib,cer*that the weQ(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 154 NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 09. copy of this record has been proviabd to the well owner.
If this is a repair,fill out hwwn well construction information and explain the nature of the
repair under#21 romvks 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 muitiple Wection or non-water supply wells ONLY with the same construction,you can
submit onefonn. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: �!� (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(exmnple T@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 casing,use"+" 1617 Matz Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Iniection Webs: In addition to sending the form to the address in 24a
Rota above, also submit a copy of this form within 30 days o€completion of well
12 Well construction method: ry construction to the following:
(i.e.Huger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injections Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-16M
13a Yield(gpm) 36 Method of test: Blowing-Rig 24c.For Water Supply&Iniection 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 constructed.
Form GW-1 - North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013