GW1-2022-01310_Well Construction - GW1_20220124

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells "
1.Well Contractor Information:
..
is WATER ZONES
Bobby W. Potts FROM I TO DFSCR1p110N
ft in ft
Well Contractor Name
NCWC 2028-A n tt
15.OUTER ING uaniti peed uedls OR L1NHR
NC Well Contractor Certification Number FROM TO 1 D1AM TFR TffiCKNFSS MATERIAL
Ferguson's Well and Pump, LLC 0 f. 3 ft I J,,), 5 i- I2 G L/
Company Name 16,INNER CASING ORTUBING
FROM TO DIANMTER I 7131cx am I MATEV.AL
L Wen Comtruction Permit N: `�`�Z ` — t� }f ft ft in
List aQ applicable we0 cor stracflon perndts(ce.Comfy,State,Yartmace,etc) ft tt
3.Well Use(check well use): 17.SCREEN
FROM I TO I DIAMERFR SLOT SIZE THICKNESS MATERIAL
Water Supply Wen: ft ft
❑pg.icultura► OMum lie
t
esidential Water Sft.OGeothesmal(Hoating/CoolinB Supply) upph'(U*k) -
OIndustrial/Commercial ❑Residential Water Supply(Shared) 18 GROUT
FROM TO MATERIAL FMPLACVMVTMElHODAAMOUNT
Ohrigation 0 ft 20 ft Concrete Grav'lty-Flow
Non-Water Supply Well: it ft
❑Monitoring oRecovery
ft. ft
Injection well:
❑Aquifer Recharge O Groundwater Remediation IGRFROM �vEL PACK���e �C r METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier & ft
❑Aquifer Test OStormwater Drainage ft. ft
❑Experimental Technologv ❑Subsidence Control 21L DRILLING LOG attar addtiooal Meets ff
❑Geothermal(Clusexl Loop) ❑Traver FROM TO DIMItIE?ION odor hardn adUroctt etc
❑Geothermal(lea' oolin Retan ❑Other(,plain under 021 Rema&sJ 17 ft ft (�
1 ft ft
4.Date Well(s)Completed: wen ma I ft ez-e dl a-r,/A.
Sa.Well Location: R L ft d wt
ft ft
Facility/Owner Name Facility IDII(if applicable) H, ft
i©toy U L icestefr 7 ft ft
Physical Address,City,and Zip 21.REMARKS r r n n
$(DQ 4 0�to'l U 6 ff 6o
Coua Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or dectmal degrees: 22.Certification:
(if well field,one IaUlong is sufficient)
F
a eZ�eZ J 0 ZZ W `"
3s�'�3 r��� lOk�N 53�
��/�' r Signature fC ed Wdl sa r �
fy-
6.Is(are)the wed(s): ®'Permanent or OTemporary By signbe dds form 1 hereby certify that the well(s)was(were)constructed m aceordauue
with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Conte+ion Stamlan*and that a
7.Is this a repair to an existing well: Oyes or 0< copy of this record has been provihd to the sreU owner.
If this is a r+epah,fill out brawn well construction Obrnaaton and explain die nature of the
o
repair wader#21 rreu wb section or on the back of dds form Y Site diagram or additional well details:
You may use the bad: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 multiple h9ection or non-water supply wells ONLY with dhe sonar COLOWC60M You amh SUBMITTAL INSTUCTIONS
submit one form
9.Total well depth below land surface: (M) 24aL For All Wells: Submit this form within 30 days of completion of well
For mzditpk wells lar all depths if d;B'erent(exmnple-3@200'and 2@1007 construction to the following:
(R) Division of Water Quality,Information Processing Unit,
10.Static water level below top of using: 1617 Mad Service Center,Raid&,NC 2769961617
If water level is above eastn,use"+"
11.Borehole diameter b
. (io) 24b.For Injection We1Lr 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 xvell
12 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 Mad Service Center,RaW&,NC 27699-1636
Method, Blowing-Rig 24c For Water SanDly&Infection Welk: In addition to sending the form to
13a.Yield(gpm) the address(es) above also submit one copy of this form within 30 days of
Chlorine oz. completion of well construction to the county health deparltnent of the county
13b.Disinfection type: Amount: where constructed.
Resources—Mvision of Water pvality Revised Jan.2013