GW1-2021-01751_Well Construction - GW1_20210430

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
Bobby W. Potts FROM TO DI23CRIP'lION
Well ContractorName ft ft
NCWC 2028-A rL tip ft
NC Well Contractor Certification Number 15 OUTER CASING or multi-med wells OR LINER d ble
FROM TO DW1dFPFR TFIICSNFSS 11AT011AL
Ferguson's Well and Pump, LLC ft ft
/tvi C z
Company Name 16.INNER CASING OR TUBING:(moodsermpiduffed
t� n FROM TO DIAMETER THICKNIE44 MATERIAL
1 Well Constriction Permit#: 0 O)0 C7t5 /'] ft ft. in.
List all applicable well eautnrctton penrdis lie.Cowdy,State,Pariance,etc.)
ft ft is
3.Well Use(check well use): 17 S/'Rft
Water Supply Well: FROM To DIAMETER SLAT SIZE I TIUCKNESS I MATERIAL
❑Agriculhual ���G�iaipal/Public ft ft to.
❑Geothermal(Heating/Cooling Supply) estdential Water Supply(single) ft ft in
❑IndustriaUCommercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATMUAL EWL.ACEMRNT METHOD&AMOUNT
❑hri anon - ft 20- Concrete y
Non-Water Supply Well: Gravity-Flow
❑Monitoring ❑Recov ft. fE
ery
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL ft
ft ft
❑Aquifer Test ❑Stormwater Drainage
ft ft
❑Experimental Technology ❑Subsidence Control
2a DRiLL1NG LOG:attKh additioostl sheets ffucamary
❑Geothermal(Closed Loup) ❑Tracur FROM TO, D]1SC2UP'1T0N color hardnes4 solUroctt etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) I 141
4.Date Wells)Completed: Well ID# ft Q
ft 7Y fL + r . fo C <
See.Well Location: Z
C O A 05ft 61v tAJ/71 C
enor-At*-, K C n d ft ft
Facility/Crooner Name nnT''II — Facility lD#(ifapplicable)
eZ N .gyp l L. QJ nn p ft. ft
r�a3�Cr O��7y8 ft ft
Physical Address,City,and Zip ICJ
21.REMARKS
'-Rt'nenm fo e 9706A(A r yap
County Parcel Identification No.(PIN) r.aar..:,i J,
5b.Latitude and Longitude in degrees/ndnutedseconds or decimal degrees: 21 Certification: CJti vJ '
(if well field,one Wong is sufficient) r
Signature of fed Well ContraclOr
6.Is(are)the well(s): QPermaneat or ❑TemporaryBy Sz ethisform I R A was()s (were)caartrwied in accordmrce
with ISA NCAC 02C.0100 or 15A NCAC'02C.0200 Well Conslruetron Standards and that a
7.Is this a repair to an existing well: ❑Yes or & o copy of this record has been praw"to the well owner
If this is a repair,fill ad known well consbvction h fotnwtion and explain the native of the
repair wider#21 remmb section or on the back of ddsfo m 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 wells constructed: I construction details. You may also attach additional pages if necessary.
Fornmdtiple byeetion or non-water supply wells OAZY with the same construction,you can
sabout are form SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: S (g) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if ahffere nt(exmnple-3@200 and 2@100') construction to the follouing:
10.Static water level below top of casing: 3(.1 00 Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
It.Borehole diameter. (in) 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 follov ing:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Marl Service Center,Raleigh,NC 27699-16M
132.Yield(gpm) 3-0 Method of test: Blowing-Rig 24c.For Water Sunnly A injection Wells: In addition to sending the form to
C the address(es) above, also submit one copy Iof this form within 30 days of
13b Disinfection e: Amount: 7 D,
t9P Chlorine OZ. completion of well construction to 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