GW1-2022-01312_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:
14.W ATER ZONES
Bobby W. Potts FROM I To DESCRWnON1
� ft
Well Contractor Name
NCWC 2028-A
15.OUTER CASING Ofturmdfl-cared wdls OR LINERK
NC Well Contracmr Certification Number FROM TO DIAMETER Tffit�tFSS MATERIAL
MG
Ferguson's Well and Pump, LLC " "` IPA /
Company Name nROM To c oR D1AML'lER �vEss MA'rMAL
I wen construction Permit#: 90.1c) —005 R - ft ft
List aAapplicable weft ca 0=11on permits(ce.Comfit Slae,Yardarr A etc.) & ft in
3.Well Use(duck well use): 17.SCREEN
FROM TO DI m=Ft SLOT SIZE TEUCI EGM MATERIAL
Water Supply Well: ft ft *+�
❑Agricultural ❑ pal/Public
ft ft
❑Geothermal(Iieating/Cooling Supply) esidential water Supply(single)
�
❑Industrial/Commercial ❑Residential Water Supply(shared) 1&GROUT
PROM TO MATERIAL F.htPLACEt1ffi`1TMEffi01)!AblOUNT
Ofirigation : 0 rc 20 ft Concrete' Gravity-Flow
Non-Water Supply well: ft ft
❑Monitoring ❑Recovery ff, ft
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation LSAPID/GRAVEL PACK fM TO opli abl MSTI1oD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft, et
❑Aquifer Test ❑Stormwater Drainage R ft
❑Experimental Technology ❑Subsidence Control Z0,ngrr.t.rnrg LOG attar$additional sheets if
❑GCuthermal(Clusexl Luup) ❑Traua FROM I TO DEBCRIPTTON Color t,arda sottAroclt etc
❑Geothermal (Heating/Cooling Return ❑Other( lain under 921 Remarks n. zo
it Oki
61 ft ( ft.
4.Date Well(s)Completed: Well IDO f it .. ft kA42 all*
5s.Well Location: 2 L ft
k lA h(i= ft tt
Facility/Owner Name —"� Facility lD#(if applicable) ft ft
l�'16 un a►�n ��1\t7� rlr ,C L e i C t-5k f t2 A Ss 7t1b ft tt
Physical Address,City,and Zip 21.REMARKS ^
nt^nm6� R76f 70 --, 4g y
Bunn, Parcel IdentiSeatioallo.(PIN)
5b.Latitude and Longitude in degrew/minntea/seconds or decimal degrees: ;2*Certifintion:
(if well ficK one Iat/long is sufficient)
4 1
s� ca ell ntcac �
6.Is(are)the well(s): er mcut or ❑Temporary By mgweg this form I hereby certify that the weQ(s)was(were)Com wted in accordoxe
with 15A NCAC 02C.0100 or IJANCAC 02C.0200 Well Construction Standards and drat a
7.Is this a repair to an e=isting well: ❑Yes or 214 copy of 1Ms record has been provided to the we11 owier.
lftks is a repair,fdl our bw m well crosavction odameoliou and explarrr dre nature of the 23.Site diagram or additional well details:
repair weder lt21 remark;section or on the back of thisfmm
/ 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 necessar)'.
For naLUpk byeedon or non-wmer supply wells ONLY with dw same cons&aCdom you Care SUBMITTAL INSTUCTIONS
submit oneform
9.Total well depth below land surface: / (fi) 24. For AR Wells: Submit this form within 30 days of completion of Well
For n=Wpk wells list all depths ifdtffereet(env*e-3 00'and 2Q1001 construction to the following:
10 (O•) Division of Water Quality,Information Processing Unit,
10.Static water keel blow top of easing.11 1617 Mao Service Curter,Rakigit,NC 27699-1617
If g
water level is above cam ,use"+
il.Borehole diameter. [J (m) 24b.For Injection Wel)s: 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 well
12 Well construction method Rotary construction to the folluvaing:
(i.e.auger,rotary,cable,direct push,ear.) Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:
1636 Maii Service Curter,Raleigh,NC 27699-1636
Blowing-Rig 24c.For Water Sannly&Injection Wells: In addition to sending the form to
13a Yield(gpm) Method.oiteat» the address(es) above, also submit one copy of this fora within 30 days of
Chlorine OZ. completion of well construction to the county health department of the county
13h.Disinfection type: Amount: where constructed
... •r_�G�_ c rL a.'...nr of Fn�ri,nmm�nr aml Nanaal Resources—Division of Water Quality
Revised Jan.2013