GW1-2022-06353_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 FROM4TER TO I DESCRIPTION
Well Contractor Name ft D ft
NCWC 2028-A - ft -No &
NC Well Contractor Certification Number 15.OUTERCASING orunitircasedwells ORLINER ifa bk
Ferguson's Well and Pump, LLC FROM ft TO Dlnr�rFR� TffiCIflVESS MATERIAL
2/.�r ?3S PdCS /CZ/
Company Name NGOR G: dosed-lau
A, FROM I TO I DIAMETER I 7H1C'RNES9 I MATERIAL
2 Well Construction Permit#: I.h a a.c ft ft. in
List all applicable well construction pernuts rte.Cowrty State,'Variance;etc.)'
ft ft in
3.Well Use(check well use): 17 5CR& I .
Water Supply Well: FROM TO DIAMEl'FR SLOT SIZE MUCENESS MATERIAL
ft
❑Agricultural ❑MuuicipaUPublic ft in.
❑Geothermal(Heating/Cooling Supply) ❑ tial Water Supply(single) ft it in
❑Industrial/Commercial residential Water Supply(shared) 18.IRtQUT r
FROM TO MATERIAL EMPLACF.MOTI METHOD AMOUNT
Non-Water Supply Well:
❑ a 0 & 20 it Concrete Gravity-Flow❑Monitoring ❑Recovery ft ft
Injection Well: ft ft
❑Aquifer Recharge El Groundwater Remediation 19 SAND/GRAVEL PACK e
FROM To I MATERIAL I EMPr••CEMENTrif 1'HOD
❑Aquifer Storage and Recovery ❑Salinity Barrier fL ft
❑Aquifer Test ❑Stormwater Drainage ft &
❑Experimental Technology ❑Subsidence Control p
20.DR1'1,LffiG LOCI.attxb additifloal sheets if
❑Geothermal(Clused Luup) []Tracer FROM TO DESCRIPTION color hardness,Altrocit Drpe,grata Am etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft Ka
`
4.Date Well(s)Completed: ��Well ID# ft. Ks- ft A9 A -r
S ft ft OC/c
az Well Location:
R S ft 669 Gt1/
!o�tlsn f r+ .�- R2b etY A Mc�u- ft ft -
Facility%dnmerName Facility M#(if applicable)
n/ R ft. k—?UZ
.207205 & ft +r
Physical Address,City,and Zip
,,rram� 21.REMARKS
.tt�C,N6A Ugtea-on -tt -Fl(A vn:0Unit
County Parcel Identification No.(PIN) D1;uQi QQ
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Ce lion
(if well field,one lat/long is sufficient)
fnq,�, N &A
vx"m /f, Ila —W
Signature of cd Well Contractor
6.Is(are)the well(s): QPermanent or ❑Temporary By signing this farm,I hereby cer*drat the weA(s)was(were)crostructed in acconlmrce
with 15A NCAC 02C.0100 or I5ANCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or copy of this record has been prow&d to the well owner.
Ifthis is a repair,fill out known well construction b¢omration and explain the nacre of the
repair wider#21 remarks section or on the back of ilus 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 inu tiple agechan or non-wader supply wells OATP with the same consrudian,you can
submit one foram SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 70J (R,) 24a. For All Wells: Submit this form within 30 days of completion of well
For nnnhiple wells list all depths if rhffermt(=w*e-3@200'and 2@100� construction to the following:
10,Static water level below top of casing: D (fL) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Marl Service Center,Raleigh,NC 27699-1617
11.Borehole diameter On-) 24b.For Iniection WeRs: In addition to sending the form to the address in 24a
Rotary above, also submit a copy of this form within 30 days of completion of well
12-Well construction method: construction to the folloving:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-16M
13a.Yield(gpm) Method of test: Blowing-Rig 24c.For Water Sunp&&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: S�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