GW1-2022-06350_Well Construction - GW1_20220705

WELL COINSTRUCTlON RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts FROM� R TOx I DESCRIPITON
Well Contractor Name ft ft
NCWC 2028-A ft ft
t 1S.OUTER CASING formnitis�d mm& OR LINERf i bk
NC Well Contractor Certification Number � ,
Ferguson's Well and Pump, LLC FROM ft TO DIAMEM THIC qM- MATERIAL
19 2
Company Name 16.INNER CASING OR . G:(mo&ernwldriedI .
FROM TO DIAME__=_ jWCJ0WM MATERIAL
2.Well Construction Permit#: o! I I e1 V I a 1 b 3 eft ft in
List all applicable well construction permits g e.Cow*,State,11arurnzA etc.)• ft ft in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAM>;TFR SLOT SIZE I TMCENM I MATERLAL
ft & in.
❑Agricultural ❑ blic
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft it in
❑Industrial/Commercial ❑Residential Water Supply(shared) -IlL GROUT _
FROM TO MATERIAL EMPLACEMENT?.WMOD AMOUNT
Non-Water Supply Well: 0
❑ Warn ft 20 ft Concrete Gravity-Flow
u--
❑Monitoring ❑Recovery ft ft
Injection Well: R ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK r1f.mmUmAl e
TO
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft ftsMAT c ERIAL EMPLACEMFMMETHOD
❑Aquifer Test ❑Stormwater Drainage '
ft. ft
❑Experimental Technology ❑Subsidence Control
20:DRILLING LOG:attsefi'addiligiral riheets if
❑Gcuthetmal(Closed Luup) ❑Tracer FROM TO DES(2tIMON color bardn soiltrocit etc
❑Geothermal(Heatin Coolin Return) ❑Other(explain under#21 Remarks) I C) ft- W .ft
ft ft
4.Date Well(s)Completed: Well ID# ft ft
C
52.Well Location: ft ft
< / C
\l j1Stt�11 ism 1 0_1 ft ft
Far.ility%•Owner Namc Facility ID#(if applicable) ft ft
p_q Ordnw rc► e n.l !',ir ft ft i 5 c.. k—t-
Physical Address,City,and Zip
Zl.REMARKS
qsqG �ir1�A t_
County PamefidentiScation go.(PIN) .• P m. ,;,
5b.Latitude and Longitude in degreeshminutes/seconds or decimal degrees: 22.Certifirstioa: v
(ifwell field,one]at/long is sufficient)
E'sf6 'r 92'"N'22 3 St.2U� wAWM.
.,' 5//?/A 2,
signature of fed Well Con for D to
6.Is(are)the well(s): ��ermmept or ❑Temporary By si8nixig this forP4 I here
by ce►trfr that the we (s)was(were)coristrueted rn accordance
with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Wdl Com&ucamStandards and that a
7.Is this a repair to an existing well: ❑Yes or 090 copy of this record has been provi&d to the well owner.
If this is a repair,fill out known well construction irrfonxation and eaplaur the nature of the
repair under#21 ranarks 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
S.Number of wells constructed: / construction details. You may also attach additional pages if necessary.
For rradtiple v9ecam or non-water supply wells ONLY with the same construdion,you can
submit onefo n / SUBMITTAL INSTUC nONS
9.Total well depth below land surface: (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For nntltrple wells list all depths ifdferml(--ple-3 tQr 200'and 2@100') construction to the follovl'ing:
10.Static water level below top of casing: A) 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) 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 method: Rotary construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injectiog Control Prggram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Blowing-Rig 24c.For Water S»nply&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 constructed
Form CAW--1 - North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013