GW1-2022-10567_Well Construction - GW1_20221121

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor I�n4formation:
IA WT—.-ZONES
Bobby W. Polls FROM4 R TO DESCRIPTION
Well Contractor Name R ft
NCWC 2028-A ft ft
NC Well Contractor Certification Number 15.OUTER CASING Iffflawrmulfi•catodwells OR LINER Ir ale
FROM TO DIAMETER TffiCKNFSSS MATERIAL
Ferguson's Well and Pump, LLC p ft ft 2 6r S [1C_So 2
Company Name 16.INNER CASING OR TUBING. dosed-lac
F FROM TO DIAMETER THIC3QgM MATERIAL
L Well Construction Permit#: ' I I O I t'ge ft ft in,
1,01 all aptpticable WU eazstructfon pernt (Le.COraty,State,'YarimrcA etc.) ft ft in.
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER 11SLUT SIZE I TMClffr M I MATERIAL
❑Agricultural ❑ rpal)Public ft ft in
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single)} ft ft le
❑Industrial/Commercial ❑Residential Water Supply(shared) i&GROUT
❑Truk anon
FROM TO MATERIAL DeL&CEMFN•T111CLMOD&AMOUNT
?
Non-Water Supply Well: ft
ft 20 & Concrete Gravity-Flow
ft ft
❑Monitoring ❑Recovery
Injection Well: & ft
❑Aquifer Recharge ❑Groundwater Remc&ation i9,SAND/GRAVEL PACK. e
TO MATERIAL EMPLACEMENTAW111OD
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft
[]Aquifer Test ❑Stormwater Drainage
ft ft
❑Experimental Technology ❑Subsidence Control DRILLING LOG.attach addit[mal sheets R r
❑Geuthemma!(Cluscd Luup) ❑Tracer FROM TO DESC'IUMON color h"dnesL soll/rwk t1pp,agn sbe,etc
❑Geothermal(HeatingACooling Return) ❑CKher(explain under 421 Remarks) Q ft Jeo st Q
4.Date Well(s)Completed: Well ID YO ft S O ft "# � R T ft
Sa.WeR Location:
S ft S[t 1
��w►es i cLu,n ft ft
Facility/Owner Name 4 FacilitylDii(ifapplicable) ft ft -
^�
ft ft
Physical Address,City,and 2ip_r
2L REMARKS
UendjeiSn An 7
COu;ty Parcel Identification
l(liviel`�"�
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
�� ct 30t�a�Ss1/N 3c/ DI . 31wFA r WpyrtAgOLZ
` //-7 A
Si tore o Certi Well for Da
6.le(are)the well(s): Li3'Permancnt or ❑Temporary
y I
By siprang this farm,I hereby terrify that the weil(s)was(were)constructed in accordance
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 214 copy ofdns record has been pnbvi&d to the well owner.
{f thts is a repair,fill out brown well conduction Wonmation and explain the nature of the
repair under#21 ranw-b section or on the back of this form 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 byectum or onus-water supply wells ONLY with the same consbuclian you can
subnot onefam SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 2,11S (ft) 24a. For Ail Wells: Submit this form within 30 days of completion of well
For nn&ple wells list all depths Vdbffetant(example-3Q200'and 2Q100� construction to the following:
10.Static water level below top of casing: y� (ft,) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699LI617
11.Borehole diameter (in.) 24b.For Injection 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
1Z Well construction method: Rotary construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injectio&Control Ptpgram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Ce i inter,Raleigh,NC 27699-1636
13a,Yield(gpm) Method of test: Blowing-Rig 24c.For Water Suouly&Iniectioa 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: I/j) OZ. completion of well construction to the county health department of the county
where constructed.
Form GW-1 - North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013