GW1-2022-01316_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.WATER ZONES
Bobby W. Potts FROM To DFSCREMON
Well contractor Name / f`
NCWC 2028-A " ft.
NC Well Contractor Certification Number 1S.OUTER CASING mMkaasad wefts OR LINER hie
FROM TO DIAMETERI TffiCIQNFSS I MATERIAL
Ferguson's Well and Pump, LLC 6 ft ; Z/bt/.(S VPC L/
Campany Name 16.11NNE11 CASING OR TUBING doled
FROM TO DIAADRFR TmaKN SS MATERIAL
2.Well Construction permit$1: A ba l - b G 5 9 K ft tc in.
List all applicable weft cantruceton permits(r.e.Comity,State,Variance etc.) ft
m.
3.Well Use(cheek well use): 17.SCREEN
Water Supply Well: mom TO DL►MLTM SLOT SIZE TffitSINFSS MATERIAL
ft ft in
❑Agricultural ❑ pal/Public
❑Geothermal(Heating/Cooling supply) Zen. water Supply(single) ft ft in.
Olndustiial/Comm FROM ercial ❑Residential water Supply(shared) GROUT
TO MATERIAL EblPLACEAffiH'f MLR801)d!AMOUNT
Mitigation 0 ft 20 ft Concrete Gravity-Flow
Non-Water supply Well: ft ft
❑Monitoring ❑Recovery ft ftInjection Well:
❑Aquifer Recharge ❑Groundwater Remediation 1%§6!%i t�iVEL PACK or oWs bin)
FROM TO Al MATERIAL + ILL tf Ft,ffiNT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft =
OAquifer Test ❑Stormwater Drainage it ft
OF.xperimental Technology ❑Subsidence Control 21L DRILLING LOG tt"IMond abeeft tr
Mcuthermal(Clused Loup) ❑Tracer FROM To DFSt.IUMON color horde SWUM& etc
❑Geothermal(Heatin lin Return ❑Other,(explain under 421 Remarks R ft m
ft 4 ft o a<
4.Date Well(s)Completed:a �� Well 1D# O ft tt
1 C
52.Well Location: 09ft ft f L
E .i1 1 i-ins 2u IC fL ft
Facility/Owner Name T— Facility MN(if applicable) ft ft JAN
t�t�5 (,i4riL�Ll te�q � �e-+ ����Lr.roc0 �.3oZ tt tt
Physical Address,City,and$ Z1.RE11fARKS
P- unCbm bd R&q S 7 1 98&
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degreeshminntes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
fl
°a4 �3< (I, N Ss _ G ", w
sigtnture of sea a for
6.Is(are)the well(s): 21 ermaneat or OTemporary By signing,this form,1 hereby cv*drat the well(s)was(were)constructed in accon mice
with 15A NCAC 02C.0100 or ISA NCAC 02C.0200♦Pell Construction Standwd;and dwt a
7.Is this a repair to an esisting wee: OYes or QNo copy of des neevndhas beat provided io the well owner.
If d&is a repatr fdl our brawn well conivuetion tr#anrntiorn and cwlabn die nature of doe
You
repair toil r,erma wider#21 fns section or on die back of des fora Site diagram or additional wellprodetails:
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 mulaple tryecam or nor-water supply wells ONLY with dw smne eouriaclioa,you con SUBMITTAL INSTUCTIONS
submit anefom.
9.Total well depth below land surface: / S (a) 24a. For All Wells: Submit this form within 30 days of completion of well
For nmNpk wells list all depdu e46ffaerrt(—npte-3@200'and 2®100� construction to the following:
10.Static water level below trap of casing: a 0 (ft) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+ 1617 Mae Service Center,Raleigh,NC 2769961617
it.Borehole diameter. ' j) Cm) 24b.For Infection Weer: 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
1L will constructionrmeWod•
Rotary constrtictiun to the following:
(ie.auger,rotary,cable,direct push,etc.)
Division of Water Quality,IJuderground Injection Control program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mae Service Curter,Raki&y NC 27699-1636
13a Yield(pin) Method of'teas Blowing-Rig 24c.For Water SaDnly&Iniection Wells: 1n addition to sending the form to
41 the addres (es) above, also submit ore copy of this form within 30 days of
136 Disinfection type, Chlorine Atsahrat a S�1 OZ• completion of well construction to the county health department of the county
where constructed.
1J. h r.. I;,.,e ri—itm.m nf F.mrimnment and Natural Resources-Division of Water Quality Revised Jan.2013