GW1-2021-02533_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. Ferguson4.WATER ZONES
.
. 9 uson .PROM TO DESC WnON
Well Contractor Name ft
NCWC 2029-A ft ft.
NC Well Contractor Certification Number 15.OUTER CASING Ow malt;-cased wells)OR LIlVER He
PROM TO D14NMTER 1ffiCSN7FSS MATERIAL
Ferguson's Well and Pump, LLC 1 0 & 1 iR 2- ,?S 1 Alc S
Company Name 16.INNER CASl2qG OR TU11G
FROM TO I DIAMETER I THICIPTU MATERIAL
2.Well Construction Permit#: dl bd,I - 0,1 b ft ft in.
List all applicable weft construct/on permits(Le.Cormty,State,Yasiance,etc.
ft It
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM I To I DIAMETER I SLOT SIZE TIU001ESS I MATERIAL
ft ft in
❑Agricultural CIuyisipal/Public
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) R ft in
❑lndustrial/Commercial ❑Residential Water Supply(shared) "L GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-water Supply Well: ft.
ft20 rc Concrete Gravity-Flow
ft ft
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK e
OAquifer Storage and Recovery ❑Salinity Barrier FROM � ft.
MATERIAL EM1q ACEMENT11WM0D
❑Aquifer Test ❑Stormwater Drainage
fL ft
❑Experimental Technology ❑Subsidence Control ,
2d IfRIId�.,---;i.OG rittoeltad�l�lsheefsR
❑Geothermal(Closed Loup) ❑Tracer FROM TO DEStT2IPT'ION color,hudn soturock d2e,etc
❑Geothermal ling Ream) ❑C+thcr(explain under 421 Remarks) ft D fL C
(� ft115 ft
4.Date Well(s)Completed: Well ID# S ft a rt
C
Sa.Well Location: R ft W
C,+ ryl Lc A g, Nn4raj 'A ft ft
Facility/OwnnerName /,, /� Facility ID#(ifapplicable) n ft.
61 HMAAKAJi U01n Dr 6G:r�riV`l 0?87317 ft ft
Physical Address,City,and Zip 21:REMARKS
1L07 t"Drr bt
County Parcel Identification No. )
5b.Latitude and Longitude in degmes/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
3sony
S gnaturo off tificd Wdl ntractor
6.Is(arc)the wcB(a): ❑getmsneat or ❑Temporary °" r
By sigrrirg this forms I hteby ce►*;that the weII(s)was(were)Constructed fn acoorxlmrce
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Consirwilon Standards and that a
7.Is this a repair to an misting well: ❑Yes or C3i'iti copy of this record has been provided to the well owner.
If fats is a repair,fill oat brown well consbuction in ormlfon and explain the natwe of the
repair render#21 remmi:s section or on the back ofiNsform 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
Formullfple agection or non-water supply wells ONLY wfth the same construes tan,you can
submit oneform SUBM]TTAL INSTUCTIONS
9.Total well depth below land surface: 7a (ft) 24a. For All Wells: Submit this form within 30'days of completion of well
For nwhiple wells list all depths ff different(cxmnple-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: 3 A) Division of Water Quality,Information P rooeaahtg Unit,
If water level is above casfng,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borebole diameter. 10 (in) In For Injection Wills: la 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 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: 16M Mall Servicel Center,Raleigh,NC 27699-16M
13a.Yield(gpm) 3 Method of test: Blowing-Rig 24c.For Water Suumly&Inlection 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 typo Chlorine Amount, kQ OZ. completion of well constructionf 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