GW1-2021-00159_Well Construction - GW1_20211213

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
,me
14:WATER ZONES i
Bobby W. Potts PROM TO DESCR]PTION
Well Contractor Name n f
NCWC 2028-A m ft
NC Well Contractor Certification Number 11 OUTER CASING wefts lHt LINER
af
FROM TO DIAMETER TBIC1104M MATERIAL
Ferguson's Well and Pump, LLC ft9dft i
Company Name 16.INNER CASING OR TUMG
FROM TO I DIA?A= I THICI NM I MATERIAL
L Well construction Permit i ba,1 - 06333 ft f in.
List aQ applicable we0 conshncdon perndis(ce.Corody.State,YarlawA etc.) it it in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: PROM TO DUNEff It I SLOT SME I THIt KMOS I MATERIAL
ft ft in
❑Agricultural paUPublic
ft
❑Geothermal(Heating/Cooling Supply) Mrmilential water Supply(single) °` -
❑Industrial/Commerrial ❑Residential water Supply(shared) M GROUT t
FROM I TO MATERIAL EMPLACEMZNTMETHOD@AMOUNT
chrization 0 rc 20 ft Concrete Gravity-Flow
Non-Water Supply Well: ft ft
❑Monitoring ❑Recovery
Injection WdL- ft ft
Recharge ❑Groundwater Remediation 19.SANDIGRAVBL PACK OF xvilcoble)
FROM TO MATERIAL METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier R ft
❑Aquifer Test ❑Stotmwater Drainage ft ft.
❑Experimental Technology ❑Subsidence Control 20.DRIi.LiNG LOG ataeh add Gmd sbweb if
❑Geothermal(Closed Loup) ❑Tracer FROM TO DFALT PTION edbr har&esa,sdUrxlt ty1w yatn say,etc
❑Geothermal(Heating/Cooling Rettun ❑Other(explain under ii21 Remarks ft 0 ft
ft ft
4.Date Well(s)Completed:/�Well IDk ft ft
5s.Well Location: 9/1
ft' ft t _
M�`y : c t
R it
Facility/Owner N Facility m#(if applicable) ft. ft UDLEf
5ia n m .y�rich, Line 3 - 2,2111D tt. ft � -
Pbvsidorl Address,C ,and Zip 21 REMARKS
an ew M br- 7(6,2
"y
CountyParcel Identifioad.No.01N)
5b.Latitude and Longitude in degreeshminutes/seconds or decimal degrees: 22.Certification:
(if well field,one latnong is sufficient)
sigmorre,pt led well Contractor
6.Is(are)the well($): eri�ent or ❑Temporary By sigrdrrg this farm,I hereby eero drat the well(s)was(were)eanstnaexd of accordance
with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 well Construcam Standards and that a
7.Is this a repair to an cidsting well: ❑Yes or MNQo copy of dds record has been proW,*d to die well owner.
If dzis is a repair,fill out baton well conaructkn b#brova lion and atphatn ire nalme of d►e
repair wider#21 remarks section or on the back of ids farm. 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 webs constructed: construction details. You may also attach additional pages if necessar).
For nuddple oyacaan or non-water supply wells ONLY with the wane 000rn400n,you can SUBMMAL ACTIONS
sub"&arwform
9.Total well depth below land surface. /C/� (rrt.) 24, For AR Wells: Submit this form within 30 days of completion of well
For rmdhpk wells list all depda tfAOired(ermnpk 3(aj200'and 2@1001 construction to the following:
10.Static water level below top of easing: (rt.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Curter,Rakdt,NC 27699-1617
11.Borehole diameter. 40 (m) 24b.For Inlection 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—11
11.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 Centex,Raleigh,NC 27699-1636
13a Yield(gpm) � _ Method of test Blowing-Rig 24e.For water suunly&bJee l was: In addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
Chlorine p oZ, completion of well construction tti the county health department of the county
13b.Dislnteclion type: Amount: ' where constructed.
i
Nat,—1 R�nmm ,C—Mvision of Water Quality Revised Jan.2013