GW1-2022-10568_Well Construction - GW1_20221121

WELL l:V1V IRUCTlON RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts 1A WATR TZOONES DESCRIPTION
Well Contractor Name ft ft
NCWC 2028-A 9 74ft
' K OUTERCAS G armnl6-case medweUs ORLINER d NC Well ContractorCatifieationNumber e
FROM TO DIAMETER I THICKNESS I MATMUAL
Ferguson's Well and Pump,-LLC ft & i- Z_/6 1 t/cS 2
Company Name 16 ER CASING OR 1VWG: deseddou
A //'�^ /� Q FROM TO DIAMETER' THICKNESS MATERIAL
2.Well Construction Permit#: d a I oo I ( 3 O 71P ft ft m
List all applicable well construcBon perndts(n.e.Cwonty,Stale,'Yarirmce,ek.)
ft ft in
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE I TE11MWM I MATFRIAT,
❑Agricultural ❑ . . lie ft ft in
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) t ft ft in
ft
❑Residential Water Supply(shared) 18-GROUT
❑lrrilion FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft 20 ft Concrete Gravity-Flow
ft ft
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/ I.PACK . e
FROM TO MATERIAL FMPI ACEMENTAW1'HOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ', ft R,
❑Aquifer Test ❑Stormwatea Drainage ft ft
❑Experimental Technology ❑Subsidence Control r
M DRILLING TAG:attidi'addidnoai cif
❑Geothermal(Closed Loup) ❑Tracer FROM TO DES(1tWn0N color hardnws6 soil/rock %bP,etc
❑Geothermal(Heating/Cooling Return ❑Other(explain under#21 Remarks) ft It.
4.Date Well(s)Completed: r� Well ID# ZO ft 3.0 ft,
ft ft O ASa.Well
Location: 2 ft r
1 S SS 1 c S ft ft
Facility706nerName Facility EX(ifapplicable) ft ft -
e hral y la r p��t�j�l�n�[d611ui l l t, t� � ft ft
Physical Address,City,and Zip 2L REMARKS
-(e.ndtf So n 364(3-Q,
C4unty Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: r
(if we field,one lat/lloong is sufficient ( 22.Certification:
3S -Zl t� 1I�11'A N _ o��A-9' SS1 ,2732t1W
Signature o ed Well Con for Da
6.Is(are)the well(s): ermanent or ❑Temporary By sigroT this form,I here
by cerhJy that the weA(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Wdl Construction Standards and that a
7.IS this a repair to an c3dsting well: Oyes or o copy of this record has been proviaW to the well owner.
If this is a repair,fdl aid Awwn well eonsbucdon infornunion and eaplaon the nature of the
repair under#21 rmwlx 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 nyecticn or non-water supply wells ONLY wilt fire same eans4uebon you can
suboat oneforrn SUBMITTAL INSTUCTIONS
9-Total well depth below land surface: 7 (B) 24a. For All Wells: Submit this form within 30 days of completion of well
For muhiple wells list all depdu if dr,Q'erent(--pie-3@200'and 2 100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Quality,Information Processing Unit,
Lf water level is above casing,use"+" 1617 Marl Service Cater,Raleigh,NC 2769961617
11.Borehole diameter: (in.) 24b.For Iniection Wells: In addition to sending the form to the address m 24a
Rota above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Rotary construction to the fulloming:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injectio&Control Prpgram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Ranch NC 27699-1636
13a.Yidd(gpm) Method of test: Blowing-Rig 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
l!36 Disinfection type: Chlorine Amount �`� 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 r
Q��ty Revised Jan.2013 ,