GW1-2021-05890_Well Construction - GW1_20211025

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts FROM TO I NES DFSCRWnON
Well ComraetorName ti" rk C
NCWC 2028-A ft ft
NC Well Contractor Certification Number 15.OUTER CASING mntti•eased wdls OR LWER hie
FROM TO DIAMETER TEICKf�M MATERIAL
Ferguson's Well and Pump, LLC & 14 j ft i 2
Company Name 16.INNER CAMNG OR G tgombernud dosed
FROM TO I DIAMETER TffiCKNE9S MATERIAL
L Well Construction Permit 6 3 An-1, _ ft. f i>L
List all applicable well construction pemmits(Le.Comity,State,Variance etc.)
ft ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM I TO DIAMMM I SLOT SIZE I TMCKNFSS MATERIAL
ft ft m
❑Agricultural ❑ ipal/Public
❑Geothermal(HeatialpCooling Supply) EgR esidential Water Supply(single) ie ft m
❑lndustrial/Commercial ❑Residential Water Supply(shared) "L GROUT '
FROM I TO MATERIAL DeLACEMENT &AMOUNT
❑ni tion 0 fc 20 ft Concrete Gravity-Flow
Non-Water Supply Well: ft ft
❑Monitoring ❑Recovery
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 1%SAND/GRAVEL PACK Of sypticable)—
FROM TO I MATERIAL IEMPLACEMIIVT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control 20,DRII ING LOG attads additional sheets if
❑ euthtamal(Clused Loup) ❑Tracer FROM TO DESCREMON color,harder soil/rock 4Tt,grain d2e,etc
❑Geothermal(Heating/Cooling Realm) l]Other(explain under 421 Remarks Q R 3,0 ft
ft J' ft
4.Date Well(s)Completed: Well DDH fr. ft C
5a.Wee Location: & ft
f1'a r gQn€ ft ft
Facility/Owner Name Facility ID#(if applicable) ft. ft
—7le Foal ner� l _a:'IzNlllt ft ft
Physical Address,City,and Zip n.REMARKS
_t.ncnwib c C?66A.37g44/So6 01119
County Parcel Identification No.(PIN) {Gl((t':1 1 se6o
5b.Latitude and Longitude in degmes/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
4S. f ed Well Contrackfir
6.Is(are)the well(s): ermanent or ❑Temporary By signing dris form,I hereby certify that die well(s)was(were)constricted in accordance
with 15.4 NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and drat a
7.Is this a repair to an existing weD: ❑Yes or O o copy of this record has been provided to the well owner.
If this is a repair,frll out bmown well construction brfommtton and uplann the natme of tie
o
repair rider#21 renaks section or on the badr of dcsform Y 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 infection or non-waer supply wells ONLY with the sane cansbuexiom,you can SUBMITTAL IN5TUCTIONS
submitoneform
9.Total well depth below land surface: ��,� (tit.) 24a. For AD Wells: Submit this form within 30 days of completion of well
For multiple welt list all depths if different(exanple-3@200'and 2Q100') construction to the following:
10.Static water level below top of casing: 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
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 e Service Center,nter,Raleigh,NC 27699-1636
13a.Yield(gpm) 30 Method of test: Blowing-Rig 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submif one copy of this firm within 30 days of
13b.Disinfection type: Chlorine Amount: y/Q OZ. completion of well construction toy the county health department of the county
6 where constructed
-..A xr.h—1 R..en--—Mvicinn of Water OualiN Revised Jan.2013