GW1-2022-10630_Well Construction - GW1_20221122

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells _
1.Well Contractor Information:
Bobby W. POI`4$ F11011f.NA TZ DESCRIPTION
Well Contractor Name E�,�,00
ft
NCWC 2028-A ft i
NC Well Contractor Certification Number 11OUTEACASING ff4wtanitiaxsbd.'wellsOR LINER
d bk
FROM TO DIAMETER THICKNESS MATERIAL
Ferguson's Well and Pump, LLC ft. 15A, ft- " c 2/
Company Name 1CL INNER CASING OR TUBII!iG. clumd-toopt
70 FROM TO DIAMETER THICKNESS MATERIAL
L Well Construction Permit#: ft ft in
List all applicable well construction pennants(i.e.County,State,Vwiance,etc.)
it ft in.
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER I SLOT SIZ I THICKNFS3 MATERIAL
n
❑Agricultural ❑ cipal/Public Ct ft i
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT _
FROM To MATERIAL E M PLACEMENT METHOD&AMOUNT
Non-Water Supply well: 0
❑ tuna ft 20 ft Concrete Gravity-
Flow
Flow
ft ft
❑Monitoring ❑Recovery,
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK.rif amamme)
To MATERIAL EMPLACEMENT11�MOD
❑Aquifer Storage and Recovery ❑ FROM Salinity Barrier ft
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control 1 r
20.DRU IMG LOG.attar additleual shaft ff
❑Geothermal(Closed Loop) ❑Tracrr FROM To DESCRIPTION color hardness,soturock ifte,etc
OGeothermal(Heating/Cooling Return ❑Other(explain under 421 Remarks) d ft ft
Is11,111,41,
ft ft
4.Date Well(s)Completed: Well ID# ft ft
Sa.Well Location: ft t f t C
K IA U S ft ft
Facility/OwnerNiunc FacilityIBf!(dapplicable) h A
tS tr _ �( Lctcasl d2S7YF ft Ct
Physical Address,City,and Zip - - 21 RE11fARKS
�'Yltotli Sc�v, $1�a 3q yyaq
County Parcel Identification No.(PIN) lwomwn .'l...,.•. -.I5b.Latitude and Longitude in degreeshninutes/seconds or decimal degrees: r' Q` 130G
22.Certification:
(if well field,one lat/long is sufficient)
3 N ��/f'S2 , SG 'Ile 'r w
Si o C ed W aurae r D
6.Is(art)the we11(5): Permanent or ❑Temporary By 47VWV I&S fO?M I fib,-r*that the weR(s)'was(were)constructed m accordance
with 15A NCAC 02C.0100 or ISANCAC 02C.0200 Well Construction Standwds and that a
7.Is this a repair to an existing well: ❑Yes or d5o copy of this record has been provided to the well owner
If this is a repa m fill out known well construction bformtion and explain the nature of the
repair under 921 rmnariks section or on the back of dusforin. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of webs constructed: construction details. You may also attach additional pages if necessary.
For multiple uffectior or noon-water supply wells OATY with the scone cansbuadion,you can
subndt are forn U SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 7 A) 24a. For All Wells: Submit this form within 30 days of completion of well
For nulhpk wells list all depths ff a lfferent(exmnple-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,
If water level is above casing,use"+" 1617 Marl Service Ccuter,Raleigh,NC 276994617
I1.Borehole diameter. (in-) 24b.For Iniection 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
T2 Well construction method: Rotary construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Piwgram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mai!Service Center,Raleigh,NC 276WI636
i
i
13a.Yield(gpm) Method of test: Blowing-Rig 24c.For Water Suonly&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: �_ e aV1 OZ. completion of well construction to(the county health department of the county
where constructed.
Form CAW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013