GW1-2021-00239_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:
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�F W.4�'ER ZONES
Bobby W. Potts FROM TO DFSCRwnoN
Well Contractor Name it. ( n
NCWC 2028-A n ft
NC Well Contractor Certification Number IS OUTER CASING multi-cased wt11s OR LIl�(!iR 6k
FROM TO DIAMLrl'FR TMCKNMSS MATERIAL
Ferguson's Well and Pump, LLC n n S (/t S
Company Name . 16.INNER CASING OR closed
FROM TO DLINMTM THICKNESS MATErtL1L
L Well Construction Permit#: rE ! & m
List at)applicable well construction pernufs(Le.Coun State,Yarlmre eta)
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3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM I TO I DIAMETER I SLOT SME I nUMM SS I MATERIAL
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❑Agricultural =tial
al/Public
❑Geothermal(Heating/Cooling Supply) Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL FMPLACFMtn?ALr HOD&AMOUNT
ClInigation 0 it 20 ft Concrete Gravity-Flow
Non-Water.Supply Well: ft ft
❑Monitoring ❑Recovery
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK df impficable)
FROM MATEMAL I DeLACENEIrf METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage ft M
❑Experimental Technology ❑Subsidence Control 20,DRILLING LOG attadr additional sbeelss if
❑t.reuthermal(Cluscd Luup) ❑Tracer ImLL
TO UFSCRiMON color,hzrdo wiurock etc
❑Geothermal(Hea' oolin Return ❑Other( lain under 421 Remarks 0 ft
Sv ft tz .
4.Date Well(s)Completed: Well ID# ft
G
5s.WeH Location: fl-
t
facility/Owner Name Facility ID#(ffapplicable) ft ft
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Physical A s,City,and Zip 21.REMARKS
ai-n 11174 -G7-""
6unty Parcel Identification No.(PIN) -
5b.Latitude and Lonotade in degreesiminotes/seconds or decimal degrees: 22.Certification:
(if well ficK one lat/long is sufficient)
.-AZZ" &Z
Signature of 'fi Co for Da
6.Is(ate)the well(s): enmanent or ❑Temporary gy si this form,1 hereby certify that the wefl(s)was(were)constructed in accordmrce
with 15A NCAC 02C.0100 0.15A NCAC 02C.0200 will Construction Stmdmrh and that a
7.Is this a repair to an existing well: Dyes or QNo copy of dds neeordhas been pmvt&d to the well owner.
If this is a repair,fill out brown well construction Wonnation mid explain the nature of the
repair under#21 ronarks section or on the bade of tires 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 wills constructed: construction details. You may also attach additional pages if necessary.
For multiple irgection or rust-water supply wells ONLY with the scone cacstradlo.You can gUBMrIT AL INSTUCTIONS
sabmut onefom.
9.Total well depth below land surface: SD (!t) 24a. For Afi Wells: Submit this form within 30 days of completion of well
Fo•mulapir wells list all depths II'd fferett(--pie-3®200'cord 2Q100') construction to the following:
10.Static water level below top of casing: f�t'/ (ft) Division of Water Quality,Information Processing Unit,
If water level is above easing,use"+" 1617 Mail Service Center,Raid&,NC 276994617
11.Borehole diameter. (in) 24b.For Iniecdon 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 construction to the fullomiug:
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Quality,Underground Injection Control Program,
FOR WATER 9UPPLY2WELLS ONLY: 1636 Mail Service Curter,Raleigh,NC 27699-1636
13a.Yield m 3 Method of teat: BlovA ng-leg 24.For Water StiIDDk&Iniectil a Wells: In addition to sending the form to
(gp ) the address(es) above, also submit'one copy of this form within 30 days of
13b Dismfectiontype: Chlorine Amount: St'7 OZ. completion of well construction to the county health deparM=t of the county
where constructed.
n__MIT i Wnnh r Tina rs'martmnns of Fnvimnmcnt and Natural Resources—Division of Water,Quality Revised Ian.2013