GW1-2021-05943_Well Construction - GW1_20211025

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
14.WATER ZONES
Bobby W. Poll1+s FROM TO DESCRIPTION
Well Contractor Name ft U6ft
NCWC 2028-A n it
NC Well Contractor Certification Number 15.OUTER CASING wetia OR LINER a irk
FROM TO DIAMETER THICKNESS MATERIAL
Ferguson's Well and Pump, LLC fc &r n. 6,1A S IAC Z
Company Name 16.INNER CASING ORTUBING(soodbermid dosed
A - / FROM TO DIAI�TER THICKNESS MATERIAL
2.Well Construction Permit#: /\ C- a 5 U yJ R• ft
List all applicable well construction pernrits ae.Cowtty,State,Yasimocrti etc.) n it in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM To DIAMETER SLOT ME THICXr4EM MATERIAL
ft tt
❑Agricultural =fial
/Public
❑Geothermal(Hen Coolin Supply) Water Supply(Single) ft ft m
❑lndustrial/Commercial ❑Residential Water Supply(shared) 11t.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD A AMOUNT
01nilzation 0 rt 20 ft Concrete Gravity-Flow
Non-Water Supply Well: ft ft
❑Monitoring ❑Recovery
ft
Injection Well: ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDltRtAVEL PACK Of applicable
FROM TO MATERLIL I EwLACEMENT AlEMOD
❑Aquifer Storage and Recovery ❑Salinity Barrier g, ft
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attxdu additional sheet it
❑Geutheamal(Closed Loup) ❑Tracer FROM I TO DESC.IUMON ftdor.hardnew saittrocle etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) f, tt a l
I- ..S ft of L
4.Date Well(s)Completed: Well ID# it. ft C
S 5a.Well Location: ft ft r
__?)AV bao a� �n4e*r, ft ft
Facility/Owner Name Facility M#(if applicable) ft ft
'-I y 6tArne,kc.l.11cAe_ W6-4nt.5tA(t AMSC, ft ft
Physical Address,City,and Zip 21.REMARKS
V1g4L00C)i -143TO
County Parcel Identification No.(PIN) Cp$51�
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: r0�m3��WR sgG�1
(if well field,one latQong is sufficient)
'30171 W
Sign orCertified Well Coa for
6.Is(are)the well(s): ermanent or ❑Temporary By signing thus form I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standar&and that a
7.Is this a repair to an c3isting well: ❑Yes or ONo copy of rMs record has been pro°khd to the well owner.
If this is a repair,fill out brown well con0vc11071 bforn otiOn and explain the nature of die
repair wider#21 remarks section or on the back of thus form. 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 muldple btfeetlorn or non-water supply wells ONLY with the sane eardruetion,you can SiJBbIITTAL INSTUCTIONS
submit one form
9.Total well depth below land surface: In S _ _(flk) 242. For Ali Wells: Submit this form within 30 days of completion of well
For nwhiple wells list all depths if dil9'er mt(=ample-3�(a 2200'/a7u12Q100') construction to the following:
10.Static water level below top of using: `T (/ (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Mad Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Rotary above, also submit a copy of this form within 30 days of completion of well
12.Well construction method construction to the fullowing:
(i.e.auger,rotary,cable,direct push etc.) Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service CI�enter,Raleigh,NC 27699-1636
13a Yield(gpm) Method of teat: Blowing-Rig 24c.For Water suoWT&Iniecho�n Wells: in addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
Chlorine OZ. completion of well construction to the county health department of the county I
13b.Disinfection type: Amount: R where constructed. V
N4t­1 R­nw.es—nivisinn of WateroualiN Revised Jan.2013