GW1-2022-10572_Well Construction - GW1_20221121

WELL UUNSI RUUTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts 14.WATER•ZONES
FROM TO nDFSCRIPTION
Well Contractor Name ft. ft
NCWC 2028-A M ft
NC Well Contractor Certification Number 15.OUTER CASING or mm6•eated veils OR LINER d bk
FROM TO DIAMETER TIUCgNM MATERLIL
Ferguson's Well and Pump, LLC � ft. ft. 'r '- S C /
Company Name Win[ / /{V 16.INNER G OR G. elmed
< I I a �$ (' FROM TO DIAME7FR TIOCICNFS3 MATERIAL
L Well Construction Permit#: V, a g �,
List all applicable well construction pemdis(Le.CoW?1y,State,*Vwiarxe,etc.)
ft ft is
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM To I DIAMETER I SLOT SIZE 1 TAICKNM MATERIAL
❑Agricultural ❑ �pal/Public ft ft. in
❑Geothermal(Heaung/Cooling Supply) =ential Water Supply(single)h D' ft in
❑lndustrial/Commerciai ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT 14WMOD&AMOUNT
❑n- aon ft 20 & Concrete Gravity-Flow
Flow
Nun-Water Supply Well: � tY-
❑Monitoring ❑Recov ft. ft
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK. e
❑Aquifer Storage and Recovery ❑Salinity Banner FROM TO MATERAL ENM ACEMENTMMOn
& f�
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft ft i e
21L DRILLING LOG:attah`adAdan l sheets if
❑Geothermal(Closed Loup) ❑Tracer FROM To DESt'RIMON color hai-daem solureclt Dy,ffwb dip,etc
❑Geothemtal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) ft t
k 9,0 fk f i 4.Date Well(s)Completed: Well 1D# ft ft
It-_Ag
Sa.Well Location- FL ftt '
L. 17
ft. ft
FaWityldwocrNlme Facility ID#(if applicable)
t ft ft
a a 4
Phvsical A ity,and Zip finsitoQ /�
R / 9�y �k 1 2L REMARKS
C9unty Parcel Identification No.(PIN) r_- ��i�P.^:3 y�.;� •'
Sh.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: .J,
(if well ficK one lat/long is sufficient)
s gnanue o ifi a ell nrractor '�
6.Is(nut)the well(s): CiFertoanent or ❑Temporary By yid this fopm 1 he-by certify that the wells)was(were)constructed m accorrirmce
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 o copy of this record has been provi&d to the wit owner,
If this is a repair,fill out brown well construction tmfomwajon and explain the nature ofthe
repair under#21 rrnrarb section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
9.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For mulopie by-am or non-water supply wells ONL with the sane consbudion,you can
subm*«ejorin. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: .US" (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For muhiple wells list all depths if a'tffermt(example-3®200'and 2®100') construction to the follwAing:
10.Static water level below top of casing: A) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter- w _ (m,) 24b.For Injection Webs: 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: Rotary construction to the folioed%:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground InjecdogControl Prpgram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-16M
13a.Yield m Blowing-Rig 24c.For Water Supply&Injection Wells: In addition to sending(gp ) Method of test: g g ding the form to
the address(es) above, also submit`one copy of this form within 30 days of
13b.Disinfection type: Chloride Amount: OZ. completion of well construction tot 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