GW1-2021-07947_Well Construction - GW1_20210809

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER2ONES'
Bobby W. Potts FROM I TO DESCRIPTION
Well Contractor Name 10 ft.
ft 15
NCWC 2028-A % lod ft
NCWeliContractorCeRificalionNumber 15.OUTER G ormald-ca ed.ltdla ORMER r l>le
FROM TO I DIAMETER TEacKNESS MATERIAL
Ferguson's Well and Pump, LLC 12 f1i ft ,�S w / 2
Company Name I&INNER CASING OR TUl31PTG: dried
o Q� PROM TO I DIAMETER I TSICKNFSS MATERIAL
L Wen Construction Permit#: R fthL
List all applicable—11 consbvcnon permits e.Cotorry,Stare,Yararce,etc.) ft ft in.
3.Well Use(check well rase): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE I THICKNESS I MATERIAL
ft &
❑Agricultural ❑ he
❑Geothermal Supply) esidential Water S s f t. ft m
(Heating/Cooling PP Y) uPP1Y(�)
❑ FR
Industrial/Commercial ❑Residential Water Supply(shared) GROUT
FROM TO MATELtrAL EMPLACEMENT METHOD&AMOUNT
01rnization 0 ft. 20 f' Concrete Gravity-Flow
Non-Water Supply Well: ft. ft
❑Monitoring ❑Recovery
fL ft
Injection Well:
❑Aquifer Recharge ❑Grounchvater Rcmediation 19.SAND/GRAVEL PACK. e
FROM TO MATERIAL I EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier R ft
❑Aquifer Test ❑Stormwater Drainage R ft
❑Experimental Technology ❑Subsidence Control 2XA(OL DRILLING LOG
❑Geothermal(Closed Luop) ❑Trace' Wr7
TO DESC'ItIFTION color,hardness,sdUrocn dx etc
❑Geothermal(Heating/CoolingReturn ❑other(explain under 421 Remarks ft a 1
y r ft4.Date Wells)Completed: Well ID# 7 RSa WeII Location: ft r C
T AWE HAA /) ft ft
Facility/Owner Name Facility ID#(if applica&-))� R ft t�
^f R�[Il�vri V ZAnE PJAI&J]!'7LIL[,A tQ
Physical Address,City,an p 21.REMARKS
County T-- Parcel Identification No.(PIN) 1G��11�,�ii0'a^ vV�;QB
5b.Latitude and Longitude m degree0ninutes/seconds or decimal degrees: 2L Certiffca'on:
G���/'p(if well field,one Iat/long is sufficient)
Signature of fled WeKontrLtor
6.Is(are)the well(s): 54�ent or ❑Temporary By 37grmig tldS forn,1 jeireby,certify that doe wells)was(were)cwutnrcred in accordance
with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Consirnretion Stardan*and that a
7.Is this a repair to an existing well: Oyes or 290 copy of this record has been pmvidedto ire well owner.
If this is a repair,fill out known well construction nfornration and explain the nature ofthe
repair order#21 ranarb section or on the back afthisform 23.Site diagram or additional wed 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 rmdlipk try ecam or non-water supply wells ONLY with the same construc0aw,you c n
submit one form SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: vs (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if d fferort(example-3@200'and 2@I00D construction to the following:
10.Static water keel below top of casing: 3� (ft) Division of Water Quality,Information Processing Unit,
If water level is above casurg,use"+^ 1617 Mail Service Center,Rald&,NC 2769-0-1617
11.Borehole diameter. (in) 24b.For 1n6—=Wells: In addition to sending the form to the address in 24a
Rota ry above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,iJndergro>md Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Ceatea,Raleigh,NC 27699-1636
13a.Yield(gpm) b Method of test: Blowing-Rig 24c.For Water Su mIv&Ini ti'mll Wells: In addition to sending the form to
the address(es) abc ve, also submit one copy of this form within 30 days of
136 Disinfection type: Chlonne Amounts OZ. 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