GW1-2022-01339_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:
24.W.�TER ZONES
Bobby W. Potts EOM DFSCPMMON
ftR TO
Well Contractor Name
NCWC 2028-A R ft.
11 OUTER CASING wens OR LINER
NC Well Contractor Certification Number PROM TO I DIAMCTER I THICKNESS I MATERIAL
Ferguson's Well and Pump, LLC R 0` C Z
Company Name JEL VOM CASING OR TIJBIItiG
PROM TO DIANE= TEaCKNES.S MATERIAL
L Wen construction Penult# a I( bb[t, 3 g 3,3 R n in.
List aU applicable weft consbucdon pemdts(ie.COsoay.Scare,Fork-e,etc.) R R is
3.Well Use(check well use): 17.SCREEN
FROM R TO DIAME1Flt I SLOT SIZE 1fIIC20 1M L.MATERIA
Water Supply Well: ft in
❑Agncultural ❑Muniei lie
R ft. �
❑Geothermal(Headog/Cooling Supply) 2 esidential Water Supply(single) _
❑Industrial/Commercial ❑Residential Water Supply(shared) 18'
FROM TO MATERIAL Fb1PLACENEgTMEIHOD@AMOUNT
❑ lion - 0 R 20 R Concrete Gravity-Flow
Non-Water supply Well: ft ft
❑Monitoring ❑Recovery ft R
injection Well
❑Aquifer Recharge ❑Groundwater Remediation �• PACK
FROM TO I MATERIAL I FatPLACEaffiS'f METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier R ft
❑Aquifer Test ❑Stormwater Drainage fL R
❑Experimental Tecbnology ❑Subsidence Control X DRIILING LOG attach adidaml Amets if
rork cuthcrmal(Closed Loup) ❑Trau r TO D=It1P 1IOId eaior e.raa ralt/
❑ MW4 aim
etc
❑Geothermal(Hea oo' Return ❑Other(explain under#2I Remarks R R
ft' R
4.Date Well(s)Completed: Well no# ft. fl. C
ss.Wen FROM Location: R ft 6-ra Wf S_
::a5huo Cor r) R ft
Facility/Owner Name Facility MN(daPPh e) ft ft
a ('Of n 40wh IZ 4{t?V�e/SpntJillC ot87�10`� R ft r
Physical Address,City,and Zap 21.REMARIM ^'1
Rt,(n ,_V,sD Y, �ito�ba�a�s4 d
County Parcel IdentiScationNo.(PIN)
Sb.Latitude and Longitude in degreeslminutea/seconds or decimal degrees: 2L Certification:
(if well field,one Iat/long is sufficient)
IV
I, ��lo r >�f�'� R' -
sigmdre 6t9oued well con tor bate
6.Is(are)the wells): QPermanent or ❑Temporary By sigrlrg this fomt 1 hereby=*that du well(s)was(were)eonst used of aecordmroe
e"-' wide 15A NCAC 02C.0100 or ISANCAC 02C.0200 Well Corm xdm Standards and that a
7.Is this a repair to an cAsftg wen: ❑Yes or 014o copy of dds record has beat provided to the well owner.
If dds is a repair,fill out baron well eoresnucfim b#bmLlim mrd ewlabt the nWm ofdre
en arks section or on de bark of ddsfonm, Y Site diagram or additional this
well details:
repair wsder#11 r
You may use the back of ts page to provide additional well site details or well
8.Number of welb constructed: construction details. You may also attach additional pages if ace ssat)
For nnddple b#ecdon or non-woer supply wells ONLY wills the amne emstrr d-;you con SUBMITTAL ACTIONS
submu omform
9.Total well depth below land surface: 0 S (it.) 24. For AR Wells: Submit this',form within 30 days of completion of well
For rmddple wells last aft depths if 4bvW(moypk 3®200'and 2Q100j construction to the following:
10.Static water level below top of casing: n (t) Divisien of Water Quality,Information Processing Unit,
If water level is above curb,,use„+„ 1617 AM Service Curter,Raleigh,NC 27699.1617
11.Borehole diameter. (m) 24b.For Iniection Wens: 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 cowtructiun to the fbHoaing:
(i.e.auger,rotary,cable,direct push,ere.) Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY:
1636 Man Service Center,RAI&,NC 27699-1636
�� � Blowing-Rig 24e.For Water Saonh&Injection VYens: 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
13b.Disinfection type: Chlorine Amount: _ oZ, completion� construction to the county health department of the county
tructed-
.. ,,.... ,.,_�,,r•.....,:-„n...„....,..e of Fmrimmmmt nett Natural Resources-Division of Water Quelity
Revised Jan.2013