_Well Construction - GW1_20230315 (73)

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts FROM TZ ONES DESCRIPITON
Well Contractor Name ft ft
NCWC 2028-A ft it.
NC Well ConuactorCertificationNumber 15.OUTERCASING fotmalti-catsodeans ORLINER rf " ble
FROM TO I DIAMETER /�NM, MATERIALFerguson's Well and Pump, LLC ft � �.
Company Name 16.INNER CASING OR TUBING.fmadiermal dosed-lao
U
2.Wen Construction Permit#: FROM TO R D1AME�ER THICKNFSS MATERIAL
in-
List all applicable well construction permits Cie.County,Stave,Vizriance,etc.)
ft ft in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DUNEC It SLOT SIZE MUCKNES3 I MATERL4I
tt ft in
❑Agricultural ❑MuwJpallPublic
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft ft iR
❑lndustrial/Commercial ❑Residential Water Supply(shared) IS..GROUT
FROM TO MATERIAL EMPLACMfENTMETHOD&.AMOUNT
❑Irri ate ft 20 ft Concrete Gravity-Flow
Flow
Non-Water,Stirpply Well:
0 ty_
❑Monitoring ❑Recovery ft ft
Injection Wen: ft &
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK . e
FROM I TO T MATERIAL I II9pLACEMENT]IMHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft -
❑Aquifer Test ❑Stormwater Drainage & ft
❑Experimental Technology ❑Subsidence Control
X DRILLING LOG.attach iddiiiand sheets if
DES
❑Geutheamal(Closed Luup) ❑Tracer FROM To CIUP'ITON color,hardness,SWING& she,etc
❑Geothermal(Heating/CoolingReturn ❑Other(explain under#21 Remarks) ft 2 O It
1 ft ft
4.Date Well(s)Completed: Well ID# ft _SSft
aa.Well Location. ftZI ft L,
kona
LIAt�a7S a 1 n.a Lac ft ft
Facility/Owner Name - Facility lD#(ifapplicable) &
G391M, U 1 JiV1�iA I 67 "R �Gp
� t`✓nSVkl o. « 744 ft ft ';..��
Physical Address,City,and Zip REMARES
•t— .t�1
=
mcGSd q��o 666 174'6Q COGO Ira ( ° 2'1
Count Parcel Identification No.(PIN)
a-b Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
rfwell ficl one)at/long 22.Ce a a:
(' d ng is sufficient)
S"c'Sel" S/ �17tAl N YA02S/St6t/27,2 W -
Si o Wcll for Da
6.Is(are)the well(s): ev.,;matrent or ❑Temporary By signing thus fornr,I hereby certify that the weA(s)'was(wen)constricted 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 wen: ❑Yes or o copy of this record has been prow&d to the well owner:
If this is a repair,fill out known well construction information and ezplain the nature of the
repair under#21 remarks section or on the back of thus form. 23.Site diagram or additional well details:
You may use the back of tins 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 hgection or non-water supply wells ONLY with the saute consbuc6ort,you con
avbrrut onefo+ SUBMITTAL INSTUCTIONS
9.Total well depth below land surface:_�(2 (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdrfferent(aroWe-3@20 '/and 2@!00') construction.to the following:
10.Static water level below top of casing: �G/ (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. (m.) 24b.For Infection WeTh Tn 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 coaryrn le method: Rotary construction to the fallowing:
(i.e.auger,rotary,cable,
,direct push,etc.)
Division of Water Quality,Underground Injectiog Control PwgMn36
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Blowing-Rig— 24c.For Water Supply&Iniection 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: I0 O 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