GW1-2022-10519_Well Construction - GW1_20221121

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts M.FROM TO TabES
• DFSCRIPlTON
Well Contractor Name ft &
NCWC 2028-A ft200
fk `
NC Well Conawtor Certification Number 15.0UTERCASING fot stdla ORLINER if ble
FROM TO DIAMETER nucE mm MATERIAL
Ferguson's Well and Pump, LLC ft-
Company ft- 1��w �' �,C 2
Company Name 16 INNER CASING OR TUBIlI7G
< FROM I TO DIAMETER I TRICKINESS MATERIAL
2.Well Construction Permit#: �O� b()_�!� ft tt in
List all applicable well cauhvction permits(i.e.County,Slote,RVarimrce,etc
fk ft in.
3.Well Use(check well use): I 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS I MATERIAL
ft ft in
❑Agrictiltural ❑ cipal/Public
❑Geothermal(Heating/Cooling Supply) esidenhtal Water Supply(single)' r ft tt in
❑Industtial/Commercial ❑Residential Water Supply(shared) 18-GROUT -
FROM TO MATERIAL EMPLACEMENT METHOD ra AMOUNT
Non-Water Supply Well:
❑ aon 0 ft 20 ft Concrete Gravity"Flow
❑Monitoring ❑Recovery ft ft
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK.rd applitable)
FROM MATERIAL EMPLACEMENT14WMOD
❑ TO Aquifer Storage and Recovery ❑Salinity Barrier R f
❑Aquifer Test - ❑Storrawater Drainage
❑Experimental Technology ❑Subsidence Control ft ft i
X DRILLING LOG attadi addid gird shy if
❑Geothermal(Clwyd Loop) ❑Truer r FROM TO DESC UMON color hardo sdlhuk slt etc
❑Geothermal(Hearin Coolin Return ❑Other(explain under#21 Remarks) ft ftNV
�1 ft c'ft
4.Date Wells)Completed: wen]ID# V n J ft
7-2 d C
Sa.Wed Location: it [t ,/'L
--lad�,^^ ft ft /
Facilrty1dWer-Name -- Facility Il l(if applicable)
-ILL ft tk
c �
Yam= L �,,ll�/ (�IY�IL Lit i Ir eu� �O O IT8 ft ft
Physical Address,City,and Zip 21 REMARKS
County Parcel Identifier'on No.(PIN) `
56.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
Signature If fiod Con for tt
6.Is(are)the well(s): epl.rmMcnt or ❑Temporary By signing this form,I hereby cer*thait the wells)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Drell Construction Standwxb and that a
7.Is this a repair to an existing wed: Oyes or 95oe copy of tins record has been provi&d to the well owner.
If this is a repair,fill out blown well construction information and explain the nature of the
repair under#21 renmb section or on the back of dwfom 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.
Formulaple irgechon or not-water supply wells ONLY with the same kwnsinucam,you can
sub»unet o form SUBMITTAL INSTUCTIONS
n ^^��
r
9.Total well depth below land surface: "U, (g) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if�ereM("anple-3@200'and�2@100') construction to the following:
10.Static water level below top of casing: A l� 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 Infection Wells: 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 fallowing:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Prggram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-16M
I
13a.Yield 0114) 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
T where constructed.
Form M-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013