GW1--04180_Well Construction - GW1_20240717

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells •
1.Well Contractor Information:
14.WATER•ZONES_
Bobby W. Potts FROM TO . f DESORPTION
Well Commotok Name ft . ' ' ft
•
NCWC 2028-A n ft
NC well Contractor Certification Number ' . 15.OUTER CASING(for szdficased wells)OR LINER(If applicable)
Qpl icable PROM TO DIAMETER . TRIMNESS MATZR IAL
•
Ferguson's Well and Pump, LLC 6 i� .,3 ft j_5 �. / iL-A5..4c$ ,
Company Name 16.INNER CASING ORTU> 4G(madam:nal desed-loop)
FROM TO DIAMLTPR T MATERIAL
L Wen tr Conauetlon Permit#: U 5 S - o�0 a 3 - l 3 a.,--i ft ft in.
List all applicable well construction permits(Le.Cownty,Story Variance etc) —
ft. ft nr.
3.Well Use(shed[well use): 17.SCREEPP
Water Supply Wen: wag TO DIAMETER. SLOT THICKNESS MATERIAL _
❑Agriculhual ❑l the ipal/Public ft ft. in. —
❑Geothermal(Heating/Cooling Supply) OR sidential Water Supply(single) ft ft in. •
—
❑Industrial/Commertial ❑Residential Water Supply(shared) 18.GROUT -
FROM TO MATERIAL ' EMPLACEMENT arratra&AMOUNT
❑hnga eon Supply Well: 0 ft 20 ft Concrete Gravity-Flow
Non-Water❑Monitoring ❑Recovery ft — ft --
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Rcmediation 19.SAND/GRAVEL PACK Cif anolics:dtel
PROM TO MATERIAL EmpurnamMETHOD
❑Aquifer Storage and Recovery ID Salinity Bather '
❑Aquifer Test ❑Stomtwater Drainageft. ft —
❑Experimental Technology ❑Subsidence Control -t
❑Geuthrrmal f'6�y..i 20.DRILLING LOG.( aditionaighats ifammary)
( Loop) ❑Tracer FROM TO (color,bardnac.sollkedr 4'Ps irsta Shit,eta)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remake) 0 it' 2p .1t clay,
4.Date wens)Completed: . // ),`/ Well mr« 249 't 95 ' 5 'y,5-i4" -c
Sit.Well Location: • 3 S ft Nj a ,rLi. ..'(%e
ft. ft.
_To,5tPh4- �r1 tr_ Li d 4/ 3 ft. OSft, Cam;, �� .
Facility/OwnerName Facility ID#(if applicable) R
() IUUr4-I- -poin- c IZ-c! I\er rSpnville Rana,) ft. ft . ...
1 Address,City,and Zip21,REMARKS
cf.-r) atrSbn Ott' : I vn tQ q ) 1 1 r
County Parcel Identification No.(PIN) lrlc.:r.:..
Sb.Latitude and Longitude in degreeslmdnutes/seconds or decimal degrees: D'
22.Certification:
(if well field,one latllong is sufficient)
_
� � ' , � r
3.S i/ /� /Y7 N 75,� �� z3, r�y�3; W , � �� - l�/� � cx
-,?/si of Certified t�,l contractor
6.Is(are)the well(s): G ar��nanmt or ❑Temporary By signing this form,I hereby cerfijy that the well(s)was(wee)conshwted in acewdrmce
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or copy 0-this record has been proviekd to the well owner.
,f this is a repair;fill oui blown well construction information and explain the nature of the
repair wrier#21 rentarks section or on the back ofthis fa n. 23.Site diagram or additional welt details:
You may use the back of this page to provide additional well site details or well
&Number of wells constructed: / construction details. You may also attach additional pages if necessary.
For ection or non-water supply wefts ONLY with the same constriction,you can form SUBMITTAL IIVSPUCTIONS
submit one
9.Total well depth below land surface t(-e'S (R,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfelifferoa(ea:mnple-3@200'and 2®io0') construction to the following:
10.Static water level below top of awing: Q ' (g,) 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. i` 62 (m.) 24b.For Infection Wens: 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
v..Well construction method: ry construction to the following:
(i.e.anger,rotary,cable,direct push.etc.)
Division of Water Quality,Underground Injection Control Pmgran,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ' Method of test Blowing-Rig 24c.For Water Snutaly&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 Amoune /, OZ. completion of well construction to the county health department of the county
tt where constructed
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013 •