GW1-2021-00301_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:
14.WATER ZONES
Bobby W. Potts FROM To I DFSCRII'nON
Well Contractor Name k /Q ft
NCWC 2028-A ft ;, ft �
NC Well Contractor Certification Number 15.OUTER CASING mdti-csed wells OR L1NSR bk
FROM I TO I DIAMETER THICKNESS MA ERIAL
Ferguson's Well and Pump, LLC tj fc I , �S i� 2 f f0,3 &c L
Company Name 16 INNER G OR TUBING dosed
� '0 f FROM TO DIAMEM TMCKNESS MATERIAL
2-Well Construction Permit#: n- ft.
List all applicable well construction permits(Le.Cowny,Stele,Variance,etc.)
ft. ft. in-
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SM THICKNESS MATERIAL
ft ft irL
OAgriculttmal ❑ cmpaUPublic
❑ m Geotheral(Heating/Cooling Supply) esideatial Water Supply(single) ft ft in.
❑lndustrial/Commeroial OResidential Water Supply(shared) 18 GROUT
FROM TO MATERIAL P2n'I.ACEMMNf METHOD de AMOUNT
0hrigation 0 rc 20 ft Concrete Gravity-Flow
Non-Water Supply Well:
tc tt
OMonitoting ORecovery
Injection Well: % tt
OAquifer Recharge OGrotmdwater Remediation 19.SAND/GRAVEL PACK e
FROM TO MATERIAL E7"LACI+,M01rr 1%MTHOD
OAquifer Storage and Recovery ❑Salinity Barrier ft. ft
❑Aquifer Test ❑Stormwater Drainage g, ft
❑Experimental Technology OSubsidence Control
20.DRILLING LOG a additional altars if
OGcutheamal(Closed Loup) OTrace r K�'
TO DFALIt TION color hardness,sdur«Ic etc
OGeothermal(Hen oolin Return ❑Other(explain under 421 Remarks ft Q
ft
4.Date Well(s)Completed: �l Well ID# 169 ft f
C
Sa.Well Location: [t L
ft. ft
Facility/Owner Name J Facility M#(if applicable) ft ft
T U24 S [ OFF1'� /2�✓ l�o i.�/1S'Ui�g 7� ft. ft
Physical Address�Zip 31.REMARKS ;f
V'o n1-*�cId D 76q DO
Coun� Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certification:
(if well Sold,one lat/long is sufficient)
--279—N SZ11 /Ix7t k73L /t waz M/A
� Signature ofC Tied Con ctor
6.Is(are)the well(s): CaJPermanent or ❑Temporary By signing this farts,1 Hereby certify that die well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Dell Construction Standards and drat a
7.Is this a repair to an existing well: ❑Yes or QNo copy of dds record has been provided to the well owner.
If this is a repair,fill out blown well construction v#brmahon and explain ire natroe of doe
repair wider#21 re orb section or on die back of dusform 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 nndaple dyection or nor-water supply wells ONLY with due same cmLWucban,you can SUBMITTAL INSTUCTIONS
submit onefom
9.Total well depth below land surface: ,�� (tit.) 24a. For All Wells: Submit this form within 30 days of completion of well
For nntluple wells list all depths tf dr8'erort(manple-3@200'and 2Q100') construction to the following:
10.Static water level below top of casing: bp (fL) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 0-) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Rota above, also submit a copy of thin foam within 30 days of completion of well
12-Well construction method: Rotary construction to the follov�ing:
(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) m 0 Mctitod of teat Blowing-Rig 24c.For Water Supply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13&Disittfecfion type: Chlonne Amount: oZ, completion of well construction to the county health department of the county
where constructed.
n-....»..,-..t,r Tz—;,n—t nM Nah-1 Racnnrces-Division of Water Ouality Revised Jan.2013