GW1-2021-00156_Well Construction - GW1_20211213

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This farm can be used for single or multiple wells
1.well Contractor Information:
14:WATER z0M
Bobby W. Potts mom To DESCRWn.ON
Well Cofactor Name a ft
NCWC 2028-A K ft
NC well Contractor Certification Number I&OUTER CASING ffm mddsaeed wells OR UK=of hie
FROM To D14NMTER I TEUC MESS MATERIAL
Ferguson's Well and Pump, LLC 5
Company Name 16.INNER CAMNG OR G
PROM TO DLAUMTER TH[CffiVFSS MATERIAL
L wen Construction Permit#: oar- ha a S a ft. ft ;a
List all applicable well construction penrdts(Le.Comity,State,Variance,etc.)
ft. n `in,
3.Well Use(check well use): 17.SCREEN
Water Supply Wen: PROM To DIAMLMM SLOT SrLE TiDcxivPss MATERLeI
ft. 1 2.
❑Agricultural ❑ Public _t_
ft
❑Geothermal(fieating/Coolmg Supply) esideatial Water Supply(single) ft. in
❑lndustri&VCommercial ❑Residential Water Supply(shared) "L GROUT
FROM TO MATERIAL neLACEMFPIT METHOD R AMOUNT
01trigation 0 rc 20 ft Concrete Gravity-Flow
Non-Water supply Well: ft ft
❑Monitoring ❑Recovery ft ft
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 1%SAND/GRAVEL.PACK e
FROM TO I MATERIAL EMPLACEMIMMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft
❑Aquifer Test ❑Stormwater Drainage R ft
❑Experimental Technolo&V ❑Subsidence Control
2tL L1Rn.t.IxgLOG athdt addlti0nal'sheet$!f
OGwthermal(Clused Loop) OTra= PROM TO DFSLRWnON hardnam6 so Mock OV,Valn dze,tee
❑Geothermal(Heating/Cooling Return) ❑Other( lain under#2I Remarks) d ft 5-5 ft L
S ft ft
a.Date Well(s)Completed: 2!wen Ina ft.
5a.Well Location: & ft
Z�r}se n r-2- r ZU ICD ft
Facility/Owner Name Facility MN(if applicable) ft ft
DU 1 2 pi
Came dreek Lave � t �r"i t:) 30 ft ft
Physical Address City,and Zip n.REMARKS
�A g1P0Sy9Ld G97 r,
County- Panel Identification No.(PIN) !l
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certificadon:
(ifwell field,one]at/long is sufficient)
3s0�0 ,Y6 qM x .2��UI so,Y9 W Of/A 12
"—�', Sight=ofCcOcd Well Contras
6.Is(are)the well(s): gPerm mcnt or ❑Temporary By sifflow Heins form,I hereby MH6 that die we (s)was(were)constructed in accordmice
with 15A NCAC 02C.0100 or 15A NCAC'02C.0200 i7ell Construeaor St—Imb and that a
7.Is this a repair to an cabling well• ❑Yc s or M o copy ofd is reeordhas been prmdded to die well owner.
If errs is a repair,fill o t known well constructionW rotation mid eaplatrt the nature ofdae
repair rider#21 nwm*y section or on die back of this four 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
&Number of wells constructed: construction details. You may also attach additional pages if necessary.
For rmddpk b#ecdm or norm-water supply wells OMYwA die seine awrsirim ice,you can SUDAUTrAL MSTUCITONS
9.Total well depth below land surfacer _(tif.) 24a. For An Wells: Submit this form within 30 days of completion of well
Fo—Ihpk veils list all depAs if4'e7n:t(--ple-3(@200'and 2©100') construction to the following:
10.Static worst keel below top of casing: (�)
Division of Water Quality,Information Processing Unit,
��
Ifwater level is above cafe,use'+' 1617 Mall Service Curter,Raleigh,NC 2769961617
11.Iiorehok diameter. D Cm) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Rotary above, also submit a copy of this fors within 30 days of completion of well
12.well construction method: ry wnsttuction to the fulluvdng:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a Yield(gpm) - Method of teat; Blowing-Rig 24e.For Water Sunnis&Infection Wells: In addition to sending the form to
the address(es) above, also submit[one copy of this form within 30 days of
136 Disinfection type: Chlorine Amount- OZ. completion of Well construction to the county health department of the county
where constructed
__....<,. >,r,...r.r....,r....rL..,.,..,-M nFF..vimmm­f AAA NAhtrAl RGcrrmcaC—111VLSInn of Water Oua11tV
Revised Jan.2013