GW1-2021-00163_Well Construction - GW1_20211213

WELL CONSTRUCTION RECORD For Intel Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER2ANES
Bobby W. Potts FROM TO DFSCPJMON
it. fL
well eontraeior Name
NCWC 2028-A
NC well Connector Certification Number M OUTER CASING udd-cased wells OR LINER lie
FROM TO DIA"rM TMCKNM MATERIAL
Ferguson's Well and Pump, LLC Q �- ft lA3'i
Company Name I6.INNER CASING ORTURM
FROM TO I DIA1aMM I THICKNESS I MATERIAL
2.Well Construction Permit M d 4al l �--6 63.� ft ft
List aA applicable-B eautnrctton pmwd&(e.e.Cow*,State,Parlance,etc.)' ft ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM To MILK FR SLOT SIZE Tffit MATERIEL
ft ft in.
❑Agricultural ❑ lic
❑Geothermal(Heating/Cooling Supply) idential Water Supply(single)
❑lndustrial/Commercial ❑Residential Water Supply(shared) F GROUT
FROM TO MATHtIAL 1SbiPLACENEn MLRHOD @AMOUNT
Ohrigation 0 20 ft Concrete Gravity-Flow
Non-Water Supply well:
is it
OMonitoring ❑Recovery
Injection Well: f`
[]Aquifer Recharge ❑Groundwater Remediation lA SAND/GRAVEL PACK Of weliglile)
FROM TO I MATIMAL IFMPLACFAffiNT NZTMD
❑Aquifer Storage and Recovery ❑Salinity Barrier g, ft.
❑Aquifer Test ❑Stormwater Dminage ft ft
❑Experimental Technology ❑Subsidence Control 21L MLLING LOG attsdi a"doml chat$it
OGeuthermal(Clused Loup) ❑Tracer FROM I TO DFB(.'RIPTTON color,hardness,Witrorte etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) I tc rt
4.Date Well(s)Completed: 3 2 Weu M# ft. ft Q R
SL Wen Location: R ft
dhen S ft. ft / DEC I
Facility/Ova=Name Facility M#(if applicable) R, ft
I-W AntmLylle Linn �� > ;�,.���� Q23a ft ft
Pby-cal Address,City.and ZAP y(.REMARKS
'����.c.
County Parcel Identific tionNo.(PIN)
5b.Latitude and Longitude in degrees/minnteslseoonds or decimal degrees: 22.Certification:
(if well field,one lamong is sufficient)
t
N ��,3 t� 2 d 321 w PAO I
Swiitu a of ertifie Well etor
6.Is(are)the wel1(s): ®Permanent' or ❑Temporary By signing Sus form,I hereby,wr*that the wen(s)was(were)casstrucled in accordance
with 15A NCAC 02C.0100 or ISANCAC 02C.0200 Well Construction Standw*and that a
7.Is this a repair to an existing well: ❑Yea or 999 copy of this record has been provided to dhe well owner.
If this is a repair,fill out brown well construction b#Zirmalion a d eaplaoe the►mama of'dre
repair raider#21 reouirb section,or ore the back ofdafoum You
m diagram or additional f this 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 necessat}'.
For mulhpk iryecam or non-water supply wells ONLY with the same consirudion,you can �MITT�INSTTJCTIONS
subnat aeeform
9.Total well depth below land surface: (11.) 242. For All Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depths if 4V-&t(eranple-3@200'and 2@1MJ construction to the following:
i
Division of Water Quality,Information Processing Unit,
10.Static avatar level below top of casing: (R-) ' NC 27699-1617
if water level is above cam,we"+ 1617 Mail Service Center,Raleigh,
it.Borehole diameter. (! (nt) 24L For Injection Wells: In addition to sending the form to the address_in 24a
above, also submit a copy of this�foim.within 30 days of completion of
11 Well construction method: Rotary construction to the following:
(i.e.anger,rotary,cable,direct push,etc.)
Division of water Quality,iTn�dsrgrnmrd Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 16m Mail Service Center,Raleigh,NC 276WI636
13L Yield(gpm) McThod o{ lso L BIQWIng-Rig Ur-For Water S�nly&Lrjection'Wells: In addition to sending the form to
the address(es) above, a submit!one copy of this form within 30 days of
13b Di�rrtection type: Chlonne Amount- y 7} QZ, completion of well construction to�the county health department of the county
where constructed
ri...,....,..,,„f F.w;n,m~er and TTannal Resnnrers-Division of water UUelitV
Revised Jan.2013