GW1-2022-01315_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: a
Bobby W. Potts FROM
4tTERZ
TOONFS DEM3UMON
Well Contractor Name 3100
NCWC 2028-A " `L
NC Well Contractor Certification Number IS OUTER CASING mdtir�ed wrJOs OR I.nYER
FROM TO DIAME'PBR MECRNMSS MATERIAL
Ferguson's Well and Pump, LLC it. -5 '_. /6t VC J
Company Name 1 CASING OR G deed
PROM TO DIAMETER TH1CIPSS MATERIAL
7-Wen Construction Permit#: o a I — 6(it) G ft ft. in.
List aU applicable well constrwilon pemdts(te.Cmahty,State,YarlmiCg etc.) R in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: ft
TO DLIbMM am SEEE TMCKIn�9 MATERIAL
tt fL
❑Agricultural ❑ ipal/Public
❑Geothermal(Heating/Cooling Supply) QResidential Water Supply(single) ft ft
❑Industrial/Commercial ❑Residential Water Supply(shared) i&GROUT
FROM TO MATERIAL EI�LACEhlEN f METEIOD di AMOUNT
❑ lion 0 fc 20 ft Concrete Gravity-Flow
Non-Water Supply Well: [t ft
❑Monitoring ❑Recovery
Injection Well: ft fL
❑Aquifer Recharge ❑Groundwater Remediation 19 SAND/GRAVSL PACK e
FROM TO I MATERIAL ° EMpI ACle1T METHOD
❑Aquifer Storage and Recovery El Salinity Barrier ft, ft
❑Aquifer Test ❑Stormwater Drainage ft, ft �
❑Experimental Technology ❑Subsidence Control yp DRILLTNG TAG ate a"doud shaft if
❑Geutheamal(Clusexl Loup) ❑Tramr FRf
TO DESCMn4ON color hide sdUroele etc
❑Geothermal(Hea' oolin Return ❑Other(explain under 421 Remarks ft Q
ft D ft t
a.Date Well(s)Completed: r Weu MN ftff
Sa.Well Location: rt
,50 L i e. ;7-te e tv M ft
Facility/Owner Name Facility
� Facility M#(if applicable) ft.
ft ft (•
7 /L -•
1 5 'Q f'lA J iC.0,5f t+- ��74 ri ft ft
Physical Address,City,and Vp 31.RrMAnme
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degmes/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one latflong is sufficient)
e S°�l l4Ytl NL'1-4 Y_fh309 'r W zz
��
6.Is(are)the well(s): al rmment or ❑Trmporary By st this form hereby aeht�y that the weft(s)was(were)ewa4nrted in aecordmhce
with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well ConsMW ianStandtmds and dwt a
7.Is this a repair to an elastmg well: ❑Yes or 09. copy oats record has been pmvisied to the weg owner.
If this is a repair Jill ota brawn well construction b#asnrdiog and explain the rattae of d►e
repair wader#21 re rarb section or on the bards o'dhis form 23.Site diagram or additional wen details:
You may use the back of this page to provide additional well site details or well
&Number of wells constructed: construction details. You may also attach additional pages if necessary'.
For mhrloiple bjecam or non-water supply wells OAZYwith dw smile emsWtmarr,you can SUBMITTAL INSTUCTTONS
submat one form
9.Total well depth below land surface: �oZ.S (ft) 24a. For All Wells: Submit this i form within 30 days of completion of well
For mub,k wells list aU depdu if 4eroht(exmnple-9®200'mhd 2@1001 construction to the following:
10.Static water level below top of casing- (tt.) Division of Water Quality,Information Processing Unit,
If water level is above casing use„+ 1617 Man Service Curter,Raleigh,NC 27699-1617
11.Borehole diameter. (m) 24b.For Iniecdon Webs: In addition to sending the form to the address is 24a
Rota above, also submit a copy of this'form within 30 days of completion of well
12.Well construction metbod Rotary construction to the fulloecing:
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Man Service Center,Raleigh,NC 27699-1636
13a Yield(gpm) _ Metitoa tr<teat Blowing-Rig ng-Rig 24e.For Water Sugigh&Injection Was: addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
Chlorine Amotmt: 5�Z, completion of well construction to the county health department of the county
13b Disinfection type: where constructed I
.. ....., �,_�,.r.-.r:..,.TL..,n....n,of Fmrimn,nr•nt m,d Nntwval ResoWtea-Division of water ludity Revised Ian.2013