GW1-2021-01768_Well Construction - GW1_20210430

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
-a>
1.Well Contractor Information:
Bobby W. Potts FROM TO DE4CRiPTiON
Well Contractor Name ft [t
NCWC 2028-A00 n ft
NC Well Contractor Certification Number 15.OUTER CASING fawr lydls OR L1NER d ble
FROM TO DIAMETER Tfi[C%PigSS MATERIAL
Ferguson's Well and Pump, LLC g � ft4.as in, �
Company Name 16.INNER CASIPTG OR G' elaaed
' O FROM TO DIAMETER THICKNE43 MATERIAL
2 Well Construction Permit#: p� ��{'Q 5- f< ft DIAMETER
List all applicable well comR)' ction permits(l e.County,Stale,Parlance,etc.)
ft ft m.
3.Well Use(check well use): 17.SCREEN
Water Supply Wen: FROM TO DIAbMTER SLOT SIZE I THICKNESS I MATERIAL
❑Agnculttual ft ft is
❑Montt pa]/Public
❑Geothermal(Head*Cooling Supply) Cil�esidential Water Supply(single) n ft UL
❑Industrial/Commercial OResidential Water Supply(shared) i&GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Ohri lion 0
- ft 20 - ft Concrete Gravity-Flow
Flow
Non-Water Supply Well: ity-
❑Monitoring ❑Recovery it. ft
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK,fff.awnllcaW.i
❑Aquifer Storage and Recovery O Salimty Barrier Barri FROM ft TQ ft MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft ft
OExperimental Technology ❑Subsidence Control
20.DRII.LiNG LOG attch additino l if
❑Geuthermal(Closed Luup) ❑Tracer FROM IN.- DESCRIP1TtNv rotor baron solllroclt etc
OGeothe mal(Heating/Cooling Return) ❑lather( lain under 421 Ronarks 4f ft70 ft t .
ft ft 4. n Date Well(s)Completed: t j Well ID# ft. �/ R
45 l�.
Sa.Well Location: ft f [t
r Q (�
t!ill gllle 1175d!' ft ft
Futility/Owaer�Nan;c // �,-, Facility ID#/(if applicable)r/,/�j K ft
W� r l�r eS LAri c �, E� a8 l`f O ft ft ,�Tg'P• j
Physical Address,City,and Zip
2L REMARKS
-
County Parcel Identification No.(PIN) Wit ;0-21
5b.Latitude and Longitude in degrees/ndi mtedseconds or decimal degrees: "�.;s;;',1,!) t i l -
(if well field,one lat/long is strtEcient) 22.Certification: j► i'1
Signature of 5ed Well Con*=tor is
6.Is(are)the wen(s): l3Permanent or ❑Temporary By Sz�g dzis fom I h—by cap*then die well($)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCACi02C.0200 Wen Coastrucdar Smndevds and drat a
7.Is this a repair to an existing well• OYes or 2NV-- copy of dhis record has been promixt io lh�e weft owner.
If this is a repair,fill aid brown well consouetion it formation and cWIcan the nature of the
repedr under#21 r mcehs•section or on the back of ddsform. 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 injection or non-water supply wells ONLY with the same eomsliuc ion,you can
$uamdl oreform SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: _(ft), 24a. For An Wells: Submit this form within 30 days of completion of well
Formultiple wells list all depdu if different(exanple-J@-2001 aa'nd 2@100� construction to the follovting:
10.Static water level below top of casing: / (ft.) Division of Water Quality,Information Processing Unit,
If wafer level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter._(ia) 24b.For Infection Wells- In additil to$coding 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 following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Centro,Rahagh,NC 27699-16M
13a.Yield(gpm) Method of test: Blowing-Rig 24c.For Water Sanely&Inaction Wells: hi 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: 50 QZ^ 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