GW1-2022-01341_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 b
Bobby W. Potts FROM I TO DESC JMON
ft ft
Well Contractor Name
NCWC 2028-A n ft P
I&OUTER CASING malti-cared wells OR LINER
NC Well Contractor Certification Number FROM TO DIAMF.TFRI THICKNM MATERIAL
Ferguson's Well and Pump, LLC i16I a no, my Am
Company Name J&t4NEKCAfflNG0RTUB1NG Bused
FROM TO DIAMETER 1ffiCXNF84 MATERIAL
L Well construction Permit M 166"t aq ft ft fa
List ag applicable we#constr flOn perWIS(re.COmily,State,Varimice etc.) ft ft is
3.Well Use(check well use): 17.SCREEN
FROM TO DIAMERER SLOT SIZE TffiC[INESS MATFRUL
Water supply well: ft ft ;n
❑Agricultural ppal/Public
ft ft. in.
❑Geothermal(Heating/Cooling Supply) 2fendCuttal Water Supply(stnglc)
❑IndustriWCommercial ❑Residential Water Supply(shared) IL GROUT +
TMETHOD
FR TO MATERIAL gMpLpCEh�1H
OM &AMOUNI
OInigAtiOu 0 rt 20 ft- Concrete Gravity-Flow
Non-Water supply well: it ft
❑Monitoring ❑Recovery
Injection Well: ft ft.
❑Aquifer Recharge ❑GroundwaterRemediation MMNDlGRAVSLPACK EIeLACEt1l8`1TMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft
❑Aquifer Test ❑Stormwater Drainage ft. Et
❑Experimental Technology ❑Subsidence Control Za DRILLING LOG attadr additisoal sheets ff
❑Gohtheamal(Clwel Loup) ❑Tracer PROM TO DESt1t1MON tw4w.halitnesk so0irneltMWetc
❑Geothermal(HeatingCooling Return) ❑Other( kin under 421 Remarks ft elo tt t
0 ft ft
Of
4.Date Well(s)Completed: Well 1D11 ft ft
Sa.Well Location: & ft LAI
YYIpr p �-- % Et
Facility/Owner Nama Facility ID#(if applicable) B ft
J - zxrfVr Jr I� � I Jkj]j1e,%nv&tt A-Tq ft ft
Physical Address,City,and Zip 21.REMARKS d
Ph�Py�� q WI l 3&5 31
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minates/seconds or decimal degrees: 22.Cerf fication:
(if well field,one hMong is sufficient)
of ILI
f� Z
",e?6 97° 11� W r
/�
Signature ofCe ed Well tractor
6.Is(are)the well(s): pKIMI'anant or ❑Temporary By sigwe this faun,1 hereby cerVy, that the weg(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or ISANCAC 02C.0200 well Conowfion Standards and drat a
7.Is this a repair to an c sting we0: ❑Yes or M<o copy of ft record has been pravkbd to dre well owner.
if dds is a repair,fell out broxm well consbvcam b¢ommdion and mplain the naMM of dre
repair render#21 rmarb section or on the bade of dusforrn 23.Site diagram or additional weli details:
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 multiple b jecaon or nowwaler supply wells ONLY wz&. do gorse ca SCRICI M you cm 9LTBMMAL INSTIICTIONS
submitoteform
9.Total well depth below land surface. I S (fL) 24a. For A I Wells: Submit this!form within 30 days of completion of well
For multipk wells list all depths tf dfferent(esmnple 3@200'and 2(a)100O construction to the following:
i
10.Static water level brow top of using: (R)
Division of Water Quality,Information Processing Unit,
" " 1617 Mail Service Center,Raleigh,NC 27699-1617
If water level is above casing,use +
11.Borehole diameter. (in.) 24b.For Injection Wells: 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 f0lloV6%: +
(i.e.auger,rotary,cable,direct push,ea.) Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Curter,Rakes,NC 27699-1636
of Blowi ng-Rig 24e.For Water Sti1nDFv&Ltieetio'Wells: In addition to sending the form to
13a Yield Mid, teat the address(es) above, also submit one copy of this form within 30 days of
completion of well construction top the county health department of the county
13b.Disinfection type: Chlorine Apt: �2 Oz. where constructed. t
.fF.n.ri.nemner ffo Nntmal Resources-Division of Water Quality Revised Jan.2013