GW1-2022-10527_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:
BobbyW. Potts 14.WATERZONES
. FROM I TO DLSCRWnoN
Well Contractor Name ft rl'0 ft
NCWC 2028-A rt tt
NC Well Contractor CcrtificationNumber 15.OUTER CASING(for mnitieasedwells)OR LINER da uble
FROM TO DW TER TMCKN cc MATERIAL
Ferguson's Well and Pump, LLC ft fl, in
Company Name 16.INNER CASING OR TUBING. dosed4ou
^ FROM TO I ImcloESS MATERIAL
2.Well Construction Permit#: AMA 66 63 7 ft ft in.
List all applicable well construction permits(t.e.Cowny,State,Variance,etc.) R ft in
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM To I DIAMETER SLOT 92F I Imck V-'m I MATERL4L
❑Agricultural ❑ pal/Public ft CL in
❑Geothermal Heatin Coolin Supply) �tial Water Su (single) ft ft in
( g/ g PP Y) PP1Y
❑Industrial/Commercial ❑Residential Water Supply(shared) 18,GROUT _
FROM I TO MATERIAL EMPLACF.NCM 11=OD&AMOUNT
❑hri ation 0 it 20 ft Concrete Gravity-Flow
Non-Water Supply Well:
ft ft
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Grounchvater Remediation 19.SAND/GRAVEL PACKrd a e
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHODft fc ,
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft ft.
20.DRILLING LOG atrxh additional sheeft f r
❑Geothermal(Closed Loup) ❑Tracer FROM TO DESCRIMON color,hardness,soilitmk glie,Vain dze,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0ft ft
Y ft ft
4.Date Well MN Completed: Well # ft ft
loll
47
Sa.Well Location: / ft ft /
/Iq�7� i G/lh /ODI/riQj ft ft
Facility wner Name Facility ID#(if applicable) ft tt r
49q9 A, (I n or-lke ✓ ,;alg j ;?hz3C, ft ft NOV 2 2022
Physical Address,City,and Zip
/,u�GairJ hP !l&114 3to L 3 moo ln(ofwmUon, Pro.360iRg UM
County Parcel Identification No.(PIN) Bee
a-b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) / 22.Certification:
350a !Y&e' dersu/i , N / A°�s'` (� ,a lr//nZ 't W
Signature f ficd n � tc
6.Is(are)die well(s): cut or ❑Temporary By signing this forum,I hereby certify that the we (s)was(were)constructed m accordance
/ with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Statdtvds and that a
7.Is this a repair to an esivtmg well: ❑Yes or awo copy of this record has been provided to the well owner.
If this is a repair,fill out known well conduction information and explain the nature of the
repair under#21 remalcs section or on the back of d&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 multiple dyaction or non-water supply wells ONLY with the same eorstruclion,you can
submit oneform SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 562-s- (ft,) 24a. For Ail Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 00''yand 2 a100') construction to the following:
10.Static water level below top of casing: /1 (ft) Division of Water Qna)[4,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
Rota above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ry construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injecting Control Pr9gram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
_ I
13a.Yield(gpm) c. or Water uipby nfection Wells: In addition to sending�i Method of test: Blowing-Rig 24 F Wt S l &I ding the form to
the address(es) above, also submit oae copy of this form within 30 days of
.13b.Disinfection type: Chloride Amount: gZOZ, completion of well construction to thIe county health department of the county
where constructed.
I
Form C W-7 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013