GW1-2021-00152_Well Construction - GW1_20211213

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I
1.Well Contractor Information:
Bobby W. rolls FR MA RTTON I DFSC'REMON
Well Contractor Name R
NCWC 2028-A n ft
NC Well Contractor Certification Number 15.OUTER CASING mnit[•cued wells OR LIlYER a ble
FROM TO DIAMETER THICKNESS MATERIAL
Ferguson's Well and Pump, LLC ft & w * i
Company Name 16.INNER G OR G doseda
a a o - FROM TO DIAMETER THICKNESS MATERIAL
L Wen Construction permit#: L111�7 ft ft in.
List ap applicable well constriction perndls(Le.Comity,Stale,Variance,etc.)
. 11. tit in. .
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICIQVFSS MATERIAL
ft fit in
[:]Agricultural2=16al
attPublic
❑Geothermal(Heating/Cooling Supply) Water Supply(single) ft ft
❑Industrial/Commercial ❑Residential Water Supply(shared) 1&GROUT '
FROM I TO MATERIAL EMPLACEMENT 11WMOD A AMOUNT
0hrixation 0 tit 20 1t Concrete Gravity-Flow
Non-Water Supply Well:
[t [t
❑Monitoring ❑Recovery
Injection wen: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK Of applicable)
FROM TO I MATERIAL I EMPLACENZNT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier fit ft
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG atrxh additional sheets if
❑Gmthesmal(Closed Loup) ❑Tracer FROM TO DES[.TtiMON ledar.bardness.aoturock etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under t121 Remarks fL v ft' GQ
39 ft. fit
4.Date Wel(s)Completed: Well MN
SS tit tcPe IWO ,c
5a.Well Location: fit fit ^Q tit e
LuAsAyi tm eV%artu fit ft
Facility/�Ow—m Name Facility MN(if applicable) fit ft
-70 Mftnhighn 2U LeiCe4eir a9141 fit fit
Physical Address,City,and lip 21.REMARKS
r'�uncornbc qy1►y3a DE 1
County Parcel Identification No.(PIN)
5b.Latitude and Longitude m degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient) i ,f !tU4011'� (1! I
� S' 'of cd Well ntrw r DatE
6.Is(are)the well(s): ZIKr nenl or ❑Temporary By agnue8 tits form 1 hereby certify that the weff(s)was(were)constructed in accordmtce
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or Cd3Vo copy of this record has been provided to the well owner.
If this is a repair,fill out blown well conduction Womration and mplatn the nature of the
repair rider#21 nemmks section or on the back of this 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 nmlliple i fecmn or rear-water supply wells ONLY with the same construction,you cue SUBAIMAL INSTUCTIONS
submit oneform
9.Total well depth below land surface: (it.) 24a. For An Wells: Submit this form within 30 days of completion of%veil
Fm nntldple wells list aAdep&s fftfiffe—t(eronple- 00'and 2@100') construction to the following:
i
10.Static water keel below top of casing: S19 ft)
Division of water Quality,Information processing Unit,
If water level is above caring use"+" 16171Vlall Service Center,Raleigh,NC 27699-1617
il.Borehole diameter. (in) 24b.For Iniection 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
IL Well construction method Rotary cunshuction 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 Ce�nfer,Ral igb,NC 27699-1636
13a Yield(gpm) Method of teat: Blowing-Rig 24c.For Water Sannly&Iniection Wells: In addition to sending the form to
the address(es) above, also submii one copy of this form within 30 days of
136 Disinfection Chlorine Amount: OZ. completion of well construction to the county health department of the county
type: where constructed
r.__. 1 1 u--,t.r t: .n.«, _..t,.r R,.v:,,n.. t .d W.t v 1 R csnncca—nivision of Water Ouality Revised Jan.2013