GW1-2022-10554_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:
14. TERM
Bobby W. Potts FROM TONES
DESCRIPiTON
Well Contractor Name ft ft
NCWC 2028-A ft ft
NC Well Contractor Certification Number 15.OUTER CASING ormdti•cased.wdls LINER f ble
FROM I i DIAMETER I imclaq SS MATERIAL
Ferguson's Well and Pump, LLC f` D ft. r a -5 " PI/C Z
Company Name 16 INNER CASING OR TUBING.
FROM TO DIAMETER nUCENFM I MATERIAL
2.Well Construction Permit#: Z y Z I — 6 y O G f< ft ;n
List all applicable well construction pennits(e.County,Sla1e,'Varimice,etc
ft ft is
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE I IMCKNM I MATERL4L
❑Agricultural ❑ ipal/Public tt ft in
❑Geothermal(Heating/Cooling Supply) p esidential Water Supply(single) f ft in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18-GROUT r
❑Irri ation FROM TO MATERIAL neUCDaNTMEMOD&AMOUNf
Non-Water$apply Well: 0 ft 20 ft Concrete Gravity-Flow
❑Monitoring ❑Recovery ft. ft
Injection Weil: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK e
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft To I MATERIAL DeLACEMENTMFMOD
f€
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft ft
2lt DRILLING LOG'.attach additimoal ngeets R r
❑Gcuthcrmal(Clused Loup) ❑Tracer FROM To DFSCREMON color hardness,soiUroclt type,ffaM d2p,etc
❑Geothermal(Heating/Cooling Return) � ❑Other(explain under#l21 Remarks) ft t t Q`
4.Date WcH(s)Completed: ;:T—Well nm ft ft C
p fL e
Sa.Well ft Location: & [t ,
M*-&114 UA 0 ft ft G
Facility1/d n ame Facility ID#(if applicable) R ft •
a!s :Tu /a /1P Lea4PvLan e 06AJ1,✓ a -)IS ft ft NOV 2
Physical Address,City,andLip 2L REMARKS
�une-a lbx $ Un:
County Parcel Identification No.(PIN) 1 i i=)'
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)t
Sigma=o ' ed W 1 e6nuutff
6.Is(are)the we0(s): ermanent or ❑Temporary
By signing tins form,1 hereby certify that the weA(s)was(were)constructed in accordwee
with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or o copy of this record has been provi&d to the well owner.
If this is a repair,fill out brown well construction ir¢omiation mad eaplarn the native ofthe
repair under#21 rernarha section or on the bark of thisform. 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 vyection onion-water supply wells ONLY with the same cros&uc ion,you can
subont aneform SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: _ 4(7 (ft) 242. For All Wells: Submit this form within 30 days of completion of well
For rrmhipk wells list all depths if dtfferenn(ez-Wk 3®2000''�and 2@100') construction to the following:
10.Static water level below top of casing: �[/ (ft) 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. _ (in) 24b.For Inieetion Wellst In addition to sending the form to the address in 24a
Rota above, also submit a copy of this foam within 30 days of completion of well
I2.Well rotaMv cable,
method: Rotary construction to the fallov�ing:
(i.e.auger,rotary,cable,direct push etc.)
Division of Water Quality,Underground Injectia&Control Ptpgram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Rabdgh,NC 27699-1636
13a.Yield Wm) Method of test: Blowing-Rig 24c.For Water Sunnly&Iniedion Wells: In addition to sending the form to
a the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chlorine Amount: �D OZ. completion of well construction to the county health department of the county
where constructed.
Form C-W-1 North Carolina Department of Environment and Natural Resources-Division of Water l2trelity Revised Ian.2013 ,