GW1-2021-02527_Well Construction - GW1_20210809

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Inform- on:
Lary/W. Ferguson 14.WATER ZONES
g FROM TO I DESCRtp1TON
Well Contractor Name ft
NCWC 2029-A ft. ft
NC Well Contractor Certification Number 15:OUTER CASING or multi-caxd wells OR UNER If bit)
FROM TO DUM ETER MECE N ESS MATERIAL
Ferguson's Well and Pump, LLC 1 0 fL ZY ft. jrK5 iR 121ht Ivy 1UC L/
Company Name 16.INNER CASING OR G
/� �y FROM TO DIAMETER TMCJtiFSS MATERIAL
2.Well Construction Permit#: A0,2 0. b 6�g ft
List all applicable well cautrwfian penrdis CU.Coway,State,Variance,etc.)
ft ft in.
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMLRE[t SLOT SIZE THICIQVESS MATERIAL
ft ft in.
❑Agricultural ❑Mimi lic
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18 GROUT
PROM TO MATERIAL EMPLACE[tM METHOD A AMOUNT
Non-Water Supply Well: 20 Concrete Gravity-Flow
ft ft
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACKfif waWlealile)
TO
❑Aquifer Storage and Recovery ❑ FROM Salinity Barrier ft ft. MATERIAL EMPLACEMENT hWMOD
❑Aquifer Test ❑Stormwater Drainage
ft ft
❑Experimental Technology ❑Subsidence Control
2ILDRILIM&:LOG a; R'
❑Gcutheamal(Clused Loup) ❑Tract• FROM TO DEW1UPnON color,hardneis,rdurock ds etc
❑Geothermal(Heatin lin Retum) ❑Other(explain under#21 Remarks ft oV,O ft
k tt
4.Date Well(s)Completed: �Ll~` Well 1D#
it ZY ft
Sol.Well Location:
& 3k5 &
4 V C
CT W 1 rm ft ft
Faci rty/Owner Namc Facility ID#(if applicable)
ft ft
Physical Address,Cfiy,and Zip 21::REM4RKS e
:St.1 r1!>Mb'is qx/le
County Parcel Ideati5ration No.(PIN)
5b.Latitude and Longitude in degmeeslmmuteslseconds or decimal degrees: 22.Certification: >>
(if well field,one lat/long is sufficient)
-f 30 SS. �lz��ft N &A A24 3 8,01 l P W
� Sigffidne of 'fled Well Co for
6.Is(are)the Well($): OPSrmancnt or ❑Temporary _r
By sigra�this form,'I h9reby certify drat the rveII(s) (were)caistnrcted in aceomlatce
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Casstrucaen Siatdaals and that a
7.Is this a repair to an existing weft: ❑Yes or CdNo copy of this record has been provided to the well owner.
If this is a repair,fill ona known well construction trformation and explain the namm of the
repair wider#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 wells constructed: / construction details. You may also attach additional pages if necessary.
For mulaple iryechon or non-watersWply wells ONLY with the sane eonsdudiae you car
sub»it cmform / SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 3 ds (ft) 24a. For All Wells: Submit this form within 30'days of completion of well
For multipk wells list all depths if d feraw(exanpk-3@2V0'and 2Q1001 construction to the following:
10.Static water level below top of casing. (g) 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. 10 010 24b.For Infection Wells: In audition to sending the form to the address in 24a
Rotary above, also submit a copy of this form within 30 days of completion of well
IL Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct posh,etc.)
Division of Water Qaaliiy,tudergeound Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 16M Mall Service Center,Raleigh,NC 27699-16M
13a.Yield(gpm) /�_ Method of test: Blowing-Rig 24c.For Water Supply&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chlorine Amount: C�� oz. Completion of Well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Naiuml Resources—Division of Water Quality Revised Jan.2013