GW1-2021-02506_Well Construction - GW1_20210809

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
LarryW. Ferguson 14.WATERZONES
9 FROM TO DESCRIPTION
Well Contractor Name ft ��D ft.
NCWC 2029-A ft. ft
NC Well Contractor Certification Number 1S.'OUTER ING(for mdti-casedirells OR LINER da ble
FROM ITO DL1MF7'FR THICKNESS MATERIAL
Ferguson's Well and Pump, LLC ft D in. C 5-pkzl
Company Name J4&1NNER CASING OR TURING d
20 2 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ��U O� ft ft in.
List aft applicable well constriction peanuts rLe.Comity,State,Variance,etc.)
ft ft inn
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICIC NFSS MATERLaL
ft ft
❑Agricultural ❑MuuicipaUPublic
ft
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) tt in
❑Industrial/Commercial ❑Residential Water Supply(shared) M GROUT
FROM I TO MATERIAL DeLACEMENT METHOD 6!AMOUNT
Non-water Supply well: 0 ft 20 ft Concrete Gravity-Flow
ft ft
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK e
FROM TO MATEPJAL EMPLACEM011TME7MOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft f
❑Aquifer Test ❑Stormwater Drainage
ft. ft
❑Experimental Technology ❑Subsidence Control
2&DRILLING LOG attach ad&tans sbroets if
❑Gcuthtamal(Closed Loup) ❑Tracer FROM To DFSLVIPTION color,hmda sWilrocic tyM gain si2e2 etc
OGeothermal(Heating/Cooling Retum) ❑Other(explain under 421 Remarks) 1 a
ft 76 ft
7 it !ft
4.Date Well(s)Completed: Well 7D# 1gS� ft e
� �C
Sa.Well Location: t
17/9 hru ft ft
Fac ity/Owner Name Facility ID#(if applicable) e
ft ft.
Co7lt'el4�e-fA IL)AU Qrc.et1 a876T ft ft ����
Physical�A,/d►drreess,s,City,and
Zip 2L REMARKS
rn
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one la�//long is sufficient) 9 '
, z til W 4A&t"' D
� Si fCo4i cd W ttac
6.Is(are)the well(s): Cror'manent or ❑Temporary
By sigrdnrg this form,1 hereby cerAify that the well(s)was(were)constructed an accordance
with 15.4 NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing wdh ❑Yes or o copy of this record has been provided to the well owner.
If this is a repair,fill ota brown well construction trforinarm and eVim the namm of the
repair wader#21 remarks section or on the back ofthisform. 23.Site diagram or additional well details:
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 b#ection or non-water supply wells ONLY with the same conslruaUn,you can
subvitt onefonn. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: C (ft) 24a. For All Wells: Submit this form within 30'days of completion of well
For multiple wets list all depths if different(example-3@200'and 2Q1001 construction to the following:
10.Static water level below top of casing: .S� (ft,) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 10 (in.) 24b.For Injection Wills: 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 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 Mail Service Canter,Raleigh,NC 27699-16M
13a Yield(gpm) Method of test: gg
Blowin RI 24c.For Water Supply&Injection Wells: In addition to sending the form to
,3r�
the address(es) above, also submit one;copy of this form within 30 days of
131► Disinfection type: Chlorine Amount: oZ. completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013