GW1-2023-02149_Well Construction - GW1_20230306

WELL CONSTRUCTION RECORD For Interal Use ONLY:
This form can be used for single or multiple wells 1
1.Well Contractor Information: •
•
Bobby W. Potts 14.WATERZONFS
FROM TO , DESCRIPTION
Well Contractor Name ft /2 0 ft
•
NCWC 2028-A ft A fe ft
NC Well Contractor Certification Number 15.OUTER CASING(formulfi-casedwells)OR LINER(if sppi1cable)
FROM TO DIAMETER THICKNESS MATERIAL
Ferguson's Well and Pump, LLC d ft 41k' ft. (prArSi 2/1, AS Prc5D�/
Company Name 16.INNER CASINGOR TUIitIDTG.( msl cl soup)
,r FROM TO DIAMETER THICKNESS MATERIAL2.Well Construction Permit#: • 3 -4 co1 U -. � ft ft in.
List all applicable well construction permits(Le.County,Stale,Variance,eta) ft ft in
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERL4L
ft ft iL
❑Agricultural ❑ blic
❑Geothermal(Heating/Cooling Supply) esi�Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 11 GRIMT -
FROM TO MATERIAL ' EMPLACEMENT METHOD at AMOUNT
❑Irrigation 0 ft 20 ft Concrete Gravity-Flow
Non-Water Supply Well: ft ft s
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GkAYEL PACK(ifamdicible)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. D' . .- '
❑Aquifer Test ❑Stormwater Drainage ft ft
:Experimental Technology ❑Subsidence Control
20.DRILLING LOG.(athdi sddi sheets if/accessary) r
❑Geothermal(Closed Loop) aTracer FROM TO DESCRIPTION(color,hardness,soilhock type,Brain sire,etc)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft �-Q* .ft ' e a,r p.
f
4.Date Well(s)Completed: 11 $R Well 11)# s ft /s�0 ft S(��/9(G� >""'
5a.Weil Location: / t Y��y ft 1 , !/1!/0 C��
dJ1940i1 `�t-I I ft ft ,. .• .. ._- . r—,.
Facility/Owner Facility ID#(if applicable) a oa
ft. ft
'300 w'I C MAR 7Q73
4 i t 3►-aeF h �� (Yl�� I^� ��7�2 ft ft •
Physical Address,City,an Zip ;.
21.REMARKS 1 . ,. ;.j-... .y
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certifieatio
ffi
r
SijgdjCon&(/ Da
6.Is(are)the well(s): Etcermanent or OTemporary By signingthis fob t hereby cer/ify that the well(stwas(were)constructed in accordance
/ with ISA NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or l O copy of this record has been provr&d to the well owner.
If this is a repair,fill out known well construction information and explain the native of the
repair wader#21 remarks section or on the back of this fonn. 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 mulliple irgection or non-water supply wells o Y with the same construction,you can
submit onefona .SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 3 CS (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tf different(example-3@200'nnand 2@100') construction to the following:
10.Static water level below top of casing: /l/ (ft) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. :`_ 4 (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
12.Well construction method: ry construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injectiop Control Prpgram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
A.V Blowing-Rig 24c.For Water Sumily&Injection Wells: In addition to sendingthe.form to
13a.Yield(gpm) Method of test: g g
the address(es) above, also submit one copy of this form within 30 days of
Chlorine SQ OZ. completion of well construction to the county health department of the county
136.Disinfection type: Amount: where constructed.
Form CAW-1 - North Carolina Department of Environment and Natural Resources-Division of Water Quality , Revised Jan.2013