GW1-2022-10552_Well Construction - GW1_20221121

W%LL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bubb W. Potts 14.WATERZONFS
Y FROM TO DESCRWnON
Well Contractor Name ft r ft f
NCWC 2028-A ft ft
NC Well Contractor Certification Number 1S.OUTER CASING for nml6 d W-10 OR LVIER f ble
FROM I TO D14YAETER nucENESSS MATERIAL
Ferguson's Well and Pump, LLC ft Z
Company Name 16 MER CASING OR TUBINGtiabodlernka dosed
< ^^ FROM TO DIAMETER MECENM MATERIAL
2.Wen Construction Permit#: d V dL L - b Uy ft ft Qt
List all applicable weft construction pennits fl.e.Coady,Slate;Vxiatce,etc.
ft ft in
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER'' SLOT SIZE TIUCKNEM MATERIAL
❑Agricultural ❑ ipal/Public [t ft in'1
❑Geothermal(Heating/Cooling Supply) 2s!dential Water Supply(single) t` R ft in
❑Industrial/Commercial ❑Residential Water Supply(shared) 11 GROUT _
FROM TO MATERIAL EMPLACEMZNT METHOD&AMOUNT
❑In aon 0 ft. 20 ft Concrete Gravity-Flow
Non-Water Supply Well: ft ft
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK e
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft it
❑Aquifer Test ❑Stormwater Drainage
ft ft
❑Experimental Technology ❑Subsidence Control
ZQ"DRILLING LO .ritta<b°adtinoal rahzti ff r
❑Geuthermal(Clused Luup) ❑Tracer FROM TO DESCRff 1TON color hardn soll/roclt etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) ft
ft s ft
4.Date Well(s)Completed: Well ED# ft ft
Sad Well Location: & ft
ft. ft
Facilityll)wneFName FacilityID#(if applicable) ft ft - y
ft ft
Physical Addtsss,City,and Zip
2L REMARKS
(lnrn hbL C�(o �l30�.
t;puaty Parcel Identification No.(PIN) vv+ P - - ^
:r4'!Z'30G
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)9
N O�'i' O�.5 `j�3z y nr W
Sigffinue of Cefied Well Contractor Da
6.Is(are)the weD(s): errnanent or ❑Temporary By signingthis forn;I hereby cer*that the well(s)was(were)corLowted in accordmhce
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construcam Standards and that a
7.Is this a repair to an e3jsdng well: Dyes or OKo copy of dos record has been provided to the well owner:
If this is a repair,fill out brown well comiruction Wommtion and esplacr the mature ofdre
repair under#21 nartants section or on the back of LWfmm 23.She 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 iryeetion or non-water supply wells ONLY with dw same oautruetion,you can
submit are form SUBAIMAL INSTUCTIONS
9.Total well depth below land surface: 74 S (tt) 24a For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depds if d erect(example— 1@200''land 2Q100') construction to the following:
10.Static water level below top of casing: '�l/ 00 Division of Water Quality,Information Processing Unit,
Ifwater level is abate casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I
11.Borehole diameter. (in.) 24b.For Infection Wells: In additioa to sending the form to the address in 24a
w 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 Injectiop Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
i
13a.Yield(gpm)_ Method of test: Blowing-Rig 24c.For Water Sunnly&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 C-W-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013