GW1-2021-02502_Well Construction - GW1_20210809 (2)

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.WeD Contractor Information:
14:wATER ZONES
Bobby W. Potts FROM ftftTO DESCRIPTION
I
Well Contractor Name i
NCWC 2028-A nA fa
ft
NC Well Contractor Certification Number 19.OUTER CASING amid-eased wdla OR LINER ble
FROM TO DIAMETFR TMCr 7q= MATERLtL
Ferguson's Well and Pump, LLC ft. ft in,
Company Name M I[NNER G OR
CASIN TUBING dosed-1
FROM TO DIAMETER TEIICKNISs MATFRLIL
L wen Construction Permit#: I Ci I Do t t q 5141 sir. ft.
List all applicable well construction permits(ate.County,State,Variance,etc.) R ft bL
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DrAMLTER SLATSM THICKNESS MATERIAL
ft ft in
❑Agricultural ft ft hL
C�£fu�ier�ai/Public
❑Geothermal(Heating/Cooling Supply) estdential Water Supply(single)
❑lndtlstrial/Commercial ❑Residential Water Supply(shared) 1S'GROUT
FROM I TO MATERIAL ]EMPLACEMENT bWMOD @ AMOUNT
OInigation 0 ft 20 ft Concrete Gravity-Flow
Non-Water Supply Well: ft ft
❑Monitoring ❑Recovery
ft ft
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 1%SAND/GRAVEL PACK Or applicalile)
FROM I TO MATEWAL FMPIACDaWhWMOD
❑Aquifer Storage and Recovery ❑Salinity Barrier & ft
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technolo&v ❑Subsidence Control Z0,DREUJKG LOG attadt additional sheets if
❑Geothermal(Closed Luup) ❑Traurr FROM I TO DF-%3 M0N valor,haMn "Ur«It etc
❑Geothermal aleatingCooling Return ❑Other(explain under#21 Remarks R -7 R l
ft Ttl ft
4.Date Well(s)Completed: Well 1D# ft it �
52.Well Location: fL ft
ft rt
Facility/Owner Name Facility ID#(if
faapplicable) ft ft A'#
Ca.-Poe4 e-v&A -rC✓t'q CC `e-a,, f-{ .Z$ I-it ft
Physical Address,City,and 21.REMARKS
lAe ulersot•N g5S86 kq o ,
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degmes/minotes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) It
eks0 f 1:t�Df`/`f.11
tSG� 533� W X's/.
S4M&;!,Ceffified Weil Contractor
6.Is(arc)the well(s): prermancut or ❑Temporary By signing this form,I hereby cer*that the wells)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards s and lint a
7.Is this a repair to an existing well: Dyes or PRooJ copy of dds record has been provided to the well owner.
If dds is a repair,fill out brown well construction Wormation and cWlabn the unarm of lee 23.Site diagram or additional well detaDs:
repair wider#21 re to kk section or of due back of ddsform
You may use the back:of this page to provide additional well site details or well
S.Number of webs constructed: � construction details. You may also attach additional pages if necessary.
For multiple injecRon or non-water supply wells ONZY with die same Construe"",you cue SUBMITTAL INSTUCTIONS
subnntt one form.
9.Total well depth below land surface: 30� (tt) 24a. For All Wells: Submit this form within 30 days of completion of well
For rnuhiple wells list all depi s if drf'erent(example-3Qa 200 and 2@100') construction to the following:
10.Static water level below top of caskW. Pit) (ft) Division of Water Quality,Information Processing Unit,
" • 1617 Mall Service Center,Raleigh,NC 2769961617
If water level Is above caking.case"+
11.Borehole diameter. 10 (ia) 24b.For Injection Wells: In addition to sending the foam to the address in 24a
Rota above, also subunit a copy of this form within 30 days of completion of well
1L well construction method Rotary construction 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 AM Service Center,Raleigh,NC 27699-1636
f
132.Yield m Method of Blowing-Rig Uc.For Water Stmaly&Infection Wells: In addition to sending the form to
tSP ) the address(es) above, also submit one copy of this form within 30 days of
Chlorine t� OZ. completion of well construction to the county health department of the county
13b.Disinfection type: Amount: where constructed
Nat„ral Rrsnnrcec-Thvision of Water,OualitV Revised Jan.2013