GW1-2021-01766_Well Construction - GW1_20210430

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts M WATER ZONES
FROM TO DESCRWnON
Well Contractor Name ft &
NCWC 2028-A n ft
7In
NC Well Contractor Certification Number 11 OUTERCMINGtTer wells)OR LINER Me
Ferguson's Well and Pump, LLC
FROM TO DIAMETER THICENM MATERIAL
' ff ' � L/IOC S oY 2�r
Company Name 16.E%WA CAMGOR TUBING': dried
FROM TO DIAMETER MOCENLSS MATERIAL
L Well Construction Permit#: - b 605� ft ft in.
List all applicable-11 const—fton pe—U(ie.County,State,IrmunrcA etc.)
tt ft in.
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER ; SLOT I TMCKNFffi I MATERIAL
OAgricultural ❑Muni tt ft is
lie
❑Geothermal(Heating/Cooling Supply) esi0 dieah'al Water Supply(single) R ft. is
❑lndustrial/Commercial ❑Residential Water Supply(shared) '1&GROUT
FROM TO MATERIAL nee ACEtrtFl�rT METHOD&AMOUNT
Non-Water Supply Well: 0
01
bon ft 20 ft Concrete Gravity-Flow
❑Monitoring ❑Recovery it ft
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/(RAVEL PACK.m mmucama
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL I ENN ACMWZNTI%MMOD
R. ft
❑Aquifer Test ❑Stormwater Drainage R ft
❑Experimental Technology ❑Subsidence Control
21L DRILLING LOG:(atta&-adadomw A nehr tf
❑Geuthermal(Clused Luup) ❑Traccr FROM TO DESt'tiIP'I'ION color.hardnem.olurodr qjw,Olin d2c etc
❑Geothermal(Heating/Cooling Return ❑Other(explain under#2I Remarks) O ft it
4.Date Well(s)Completed: Well ID# 71 7 ft
Q R ez R
Sa.Well Location: 7 tt ft /1 C
AIie.LS Unn,Jer14nl1j( _ fL ft
Facility/Owner Name Facility III#(if applicable) ft ft
Ir r cCr�m lit`I 1 I? L . �e.y ft ft g'!.!4._•u - ` °��
Physical Address,City,and Zip 21 REMARKS
LA1a,:nrrr� l^ 6 i�,-
County Parcel Identification No.(PIN) Uri
5b.Latitude and Longitude in degrees/minutes/Seconds or decimal degrees: 2L Certification:
(if wcfl field,one lat/long is sufficient) q'm/,
3.J 37S0�S���/rZ tr N �T y '!p W 1.z /r W
� Signature of ed Well Con
6.Is(ate)the well(s): 2Fermanent or ❑Temporary By signing form I hereby oerfiJy that the weff(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 WeH Construction Standmtly and that a
7.Is this a repair to an existing well: ❑Yes or copy ofdds record has been provided to the well owner.
If this is a repair,fd l out known well eonsoucdon h#ornart lon and explain the nature of the
repair under#21 rmanAs section or on the back of AWfmm 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 multiple hyectim or non-water supply wells ONLY with the same constiudian,you can
submit are fam SUBMITTAL INSTUCTIONS
Q
9.Total well depth below land surface. 3pS (g,) 24a. For All Wells: Submit this form within 30 days of completion of well
For nm&ple wells list all depdu if d0erent(exmnple-3@200'and 2@100') construction to the folio,%*:
10.Static water level below top of casing: A) Division of Water Quality,Information Preceasf®g Unit,
If water level is above casing,use"+" 1617 Mail Service Cuter,Raleigby NC 27699-1617
11.Borehole diameter kpn (in) 24b.For Iniectlon Wells: In addition to sending the form to the address in 24a
Rota above, also submit a copy of this form within 30 day Is of completion of well
12.Well construction method: Rotary construction to the follovdrig:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Curter,Raleigh,NC 27699-1636
13a.Yield m Blowing-Rig- 24c.For Water Sannly&Injection Wells: In addition to sera th
(gp ) Method of test: �ge form to
the address(es) above, also submit tine copy!of this form within 30 days of
13b.Disinfection type: Chlorine Amount: SO OZ- completion of well construction to the icounty' 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