GW1-2021-05891_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:
14:WATER ZONES P
Bobby W. Potts FROM TO DESCREMON
Well Contractor Name rt Al
ft
NCWC 2028-A rt rt
NC Well Contractor Certification Number M OUTER G(for multi cased welk OR LINER a ble
FROM TO DIAMETER llaacVESS MATERIAL
Ferguson's Well and Pump, LLC ft !ind 2 Ik f AS C
Company Name 16 iNNTER CASIPJG OR TUBING dueedago
FROM To DL4?dr x I IMCICNM I MATERUL
L Wen Construction Permit#: 05 ft- N' in.
List all applicable well construction permits fl e.Comity,State,Yartana;etc.) fL ft in.
3.Well Use(check well use): 17.SCREEPI
Water Supply Well: FROM I TO I DIANIMIR SLOT SIZE I IMCK14FFM MATERIAL
ft ft f3L
❑Agricultural ❑Munie
❑G 'pal/Public
eothermal(Heah4Cooling Supply) esidential Water Supply(single) ft ft
❑Industrial/Commercial ❑Residential Water Supply(shared) 1&GROUT '
FROM TO MATERLfL EMPLACM!N'f METHOD!AMOUNT
01m tion . 0 ft 20 ft Concrete Gravity-Flow
Non-Water Supply Well: ft ft
❑Monitoring ❑Recovery
ft
Injection Well: ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK e
FROM I TO MATERIAL 0"LACENIM MTHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft
❑Aquifer Test ❑Stormwater Drainage ft [t
❑Fxperimetrta!Technology ❑Subsidence Control 20.DRII.LIIdG TAG attadr additional steels if
❑Geothermal(Clused Luup) ❑Tracer FROM I TO DESCR.WrION color,bards W[frock grain d2r,etc
❑Geothermal(HcatmgACooling Return) ❑Other(explain under 421 Rcmarksj ft. ft
& qO ft
4.Date Well(s)Completed: Well ID# Q ft ft
5a.Wen Location: ft ft
ft
F lity/Ow'a Name Facility MN(if applicable) ft. ft
Physical Address,City,and Zip 21.REMARKS
,nChJ��C CI70 a15 US ss
County Parcel Identification No.(PIN) �m3� RSeC
5b.Latitude and Longitude in degrees/minutes/sawnds or decimal degrees: 22.Certification:
(ifwell field,one
/lat/long is sufficient) r
v /_f p
d'7�1/If�d QS I �N I��`7it l�� 12 VV
Signature of ed Well Contracto Da
6.Is(are)the well(s): ermanent or ❑Temporary By signing this form,I hereby cer*that the we11(s)was(were)comstrueted in accordance
with 15A NCAC 02C.0100 or 15A NCAC i02C.0200 well Construction Stardauk and that a
7.Is this a repair to an existing well. Dyes or QNo copy of this record has been provided to the well owner:
If this is a repay,fill old(brown well construction 3 fonnalion and explain the nature of the
repair W der#21 remelts section or on the back of Ais form 23.Site diagram or additional well details:
1 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 necessay.
For multiple byection or nor-water supply wells ONLY with the sane constrrlc6oR you can SUBb1ITPAL INSTUCTIONS
submit oneform
9.Totai well depth below land surface: (fit.) 24a. For All Wells: Submit this form within 30 days of completion of well
For nwhiple wells list all depths ii a�tfferett(exanple-3(;200'am12Q1007 construction to the following:
10.Static water level below top of casing: YV (ft) Division of Water Quality,Information Processing Unit,
If waerlevel is above casfng,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
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 Mall Service Center,Raleigh,NC 27699-1636
13a Yield m Metiuod,of teat: Blowing-Rig 24e.For Water SuoDly&IniectionlWells: In addition to sending the form to
(gP ) the address(es) above, also submit lone copy of this form within 30 days of
13h.Disinfection type: Chlorine Amount: Gl/ OZ. completion of well construction to the county health department of the county
where constructed
Revised Jsn.2013