GW1-2022-06346_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:
Bobb W. Potts 14.WATERZONFS =
Y FROM TO DESCRIPTION
Well Contractor Name ft ft
NCWC 2028-A ft 0o &
' 15.OUTER CASING formuld-cesedadls ORLINER d ble
NC Well Contractor Certification Number - r
FROM I TO I DIAMETER ITffiCKNETS MATERIAL
Ferguson's Well and Pump, LLC ft- X ft. ("A ?W � cc
Company Name 16.INNER CASING OR TUBING dosed-lob
s FROM TO D1AMEIFR THICKNESS MATERIAL
2.Well Construction Permit#: j + d 9�i'8'7 D ft ft ;R
List all applicable well construction Pt—fl.e.ICo!+a�ty C State,°lrarrance,etc.).
ft ft in
3.Well Use(check well use): 17,SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural []Muni blic ft ft in
❑Geothermal(Heating/Coohng Supply) widen Water Supply(single) ft ft ire
❑Industrial/Commercial ❑Residential Water Supply(shared) 18'GROUT... _
FROM TO MATERIAL EMPLACEt1tM1iTA=OD&.AMOUNT
Non-Water Supply Well:
❑hri Lion 0 ft 20 ft Concrete Gravity-Flow
❑Monitoring ❑Recovery ft. ft
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediatiou 19.SAND/GRAV]9L-PACK. e
❑Aqu FROM To MATERIAL EMPLACEN"TAW1'HODifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stomtwater Drainage j
ft ft
❑Experimental Technology ❑Subsidence Control P
7A DRILLING LOG.ittsch additi m.1 sheets if
❑Geuthetmal(Closed Luup) ❑Tracer FROM TO DFSCitEMON color,hardness,solUroctt Azz,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) n ft .ft
t ft
4.Date Well(s)Completed: We111D# ft ftlog
Sa.Well Location:: Ct j ft
4A I lao to Loa r ft ft °
y
FacrlityfOwmerName Facility ID#(ifapplicable) ft ft
rn t=�Lt.re &A dE,-S cr)ed le 9 1 7q 3Lft ft
Physical Address,City,and Zip 21-REMARIM
1-6Jerdnn 06a 13 6.563`SL/ ve
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/smonds or decimal degrees:
22.Certification:
(ifwcll field,one lat/long is sufficient)
_N Al/'01
S gna Tied Well Contractor ate
6.Is(are)the well(s): • ermanent or ❑Temporary
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
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 o copy of this record has been provi&d to the well owner.
If lhis is a repair,fill out known well construction o:fornwtion and eVkrin the nature of the
repair under#21 rentarke 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 multiple trgectton or non-water supply wells ONLY with the same cons&ue ion,you can
subndl areforma r SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 74 7 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ffdifferent(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of using: kQ (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:46 40 (in.) 241b.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
IZ Well construction method: ry construction to the fbHoming:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground injection Control Prggram,
FOR WATER SUPPLY aWELLS ONLY: 1636 Mail Service Centex,Raleigh,NC 27699-1636
13a.Yield(gpm) / Method of test: Blowing-Rig 24c.For Water Sumoly&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: 67 OZ. completion of well construction to the county health department of the county
where constructed.
Form C W-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013