GW1-2022-01413_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 DESCKMON
ft
well contractor Name 0 ft
NCWC 2028-A ft f`
NC well Contractor Certification Number 1S OUTER CASING mniti.eated weft OR ilm hie
FROM TO I DIAN TER JMC 0,CM MATERIAL
Ferguson's Well and Pump, LLC ft i- C
Company Name a G ORITJBIIOG closed
FROM TO DIAMETER TBICENES4 I MATERIAL
L Well construction Permit a: p fa ft ft is
List ail applicable well eornowfion permits ge.Cmahty,State.Yarlannee,etc.) n, ft is
3.Well Use(check well use): 17.SCREEN
Water Supply Well: mom TO I DIAMEIFR SI OT SD.E I TlucItMM IMATERIAL
ft ft is
❑Agricultural 13MM
❑Geothermal(Heating/Cooling Supply) esidenhal water supply(Single) ft rt in.
GROUT
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18
FROM TO MATERIAL F1tlpLACE[Mf MISIHOD B AMOUNT
01MRation 0 ft 20 ft Concrete Gravity-Flow
Non-Water Supply well: ft ft
❑Monitoring ❑Recovery
ft
Injection WdL• fL
❑Aquifer Recharge []Groundwater Remediation 19.&4NDbGRAVBL PACK Or
FROM TO I MATItRUL I DeLAMO NT bWMOD
❑Aquifer Storage and Recovery ❑Salinity Barrier g
❑Aquifer Test ❑Stormwatcr Drainage R ft
❑Experimental Technology ❑Subsidence Control 21L DREL ING LOG attadt additioosl sbeefs ii
❑Geuthermal(Closed Loup) ❑Tracer FROM I TO DFALItM 1TON jqowr bardness,Wbtoclt etc
❑Creothermal(HeatingCooling Rearm) ❑Other(explain under 1121 Remarks R IL Q
ft ft S'
4.Date Well(s)Completed: Well lUk ft tt
L
Sn.Well Location: ft ft w t
(11 Se �. h is i3c�sy ��r & ft
Faclility/Owner Name Facility MN(if applicable) ft t f
�.3�+Idl.Li..Te- r ft ft ,
Physical Address,City.and Zip 21.REMARKS
n.�,1A J 1-xA 1 l to
County PateelIdentifieationNo. PIN)
5b.Latitude and Longitude in degreestminutea/seeonds or decimal degrees: 2L Certification:
(if well field,one lat/long is sufficient)
�a�Q Q1, /1 N dR' /Ale,
S' of ' ed for
6.Is(are)the well(s): 2KrmanMt or ❑Temporary By agr bg this form,1 hereby oet*that the well(s)was(were)constructed in accon*nce
with 15A NCAC 02C.0100 or 15ANCAC 02C.0200!Pell ConWw im Startdcmds and that a
7.Is this a repair to an existing wen: ❑Yea or C31To copy of dds record has been pmvi&d to the well owner.
If this is a repair,fill oga brown well emsructiou hdbrmatiog clad explain the nalt-Vie
repair under N21 reaarl:c section or on the back of dds for. 23.Site diagram or additional well detans:
You may use'the back of this pageto provide additional well site details or well
&Number of was constructed: construction details. You may also attach additional pages if necessal).
For nUMAPle b►fecaw or non-water supply wells My with die same canstrrtcrSae,You can SUBMITTAL INSTUCTIONS
submit one form
9.Total well depth below land surface: (ft) 24a. For Ail Well: Submit this form within 30 days of completion of well
For multiple wells list all depths if 42nw(cw*e-3®200'and 2@100� construction to the following:
f
lo.Static water level below top of casing: (ft) Division of Water Quality,Information Processing Unit,
If water level is above easing,use"+" 1617 Mail Service Center,Rald&,NC 27699-1617
11.Borehole diameter. (m) 24b.For Iniecdon WeIIr. 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
12.Well construction method Rotary omstruction to the following:
(i.e.auger,rotary,cable,direct push,etc.) Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Ma8 Service Center,Raleigh,NC 27699-1636
13a Yield(gpm) Method of teat Blowing-Rig 24e.For Water SronFv&Iniecti f Wells: In addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
Chlorine I!t! OZ. completion of well construction to the county health department of the county
13b Disinfection type: Amomr. where constructed
Tl...,.,.. m of Rmrim—nt and Nah, l R esonmcr_s—Division of water 0aslitY Revised Jan.2013