GW1-2021-02557_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:
14.WATER ZONES
Bobby W. Potts FROM TO I DESCRIPTION
Wen Contractor Name ft. elt,40 R
NCWC 2028-A ft 60 ft
NC Well ContractorCertificalionNumber 15.OUTER CASING ot'nt�ti eA.weDa OR LUM r ble
FROM I TO I DIAMEM mmaa'Fm MATERIAL
Ferguson's Well and Pump, LLC f° 1 9 T ft1 2, h N UCH Z/
Company Name 16.INNER CASING OR TtJ131TTG: erased
^ FROM TO I DIAMETER NESS THICK MATERIAL
2.Well Construction Permit#: 90 d( d$ & f< I m'
List all applicable well construction pemrits(ie.County,State,Variance,etc.)
R ft in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM To DIAMETER SLOT SIZE TIHCKNM MATERIAL
ft ft in.
❑Agricultural ❑ pal/Public
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT.
FROM TO MATIRTAL EMPLACEMEIST METHOD rs AMOUNT
01mization 0 rt 20 ft- Concrete Gravity-Flow
Non-Water Supply Well:
ft tt
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK
PROM TO MATERIAL EMPLACEMFIV T MEMOD
❑Aquifer Storage and Recovery ❑Salinity Barrier tt ft
❑Aquifer Test ❑Stolmwater Drainage R R
❑Experimental Technology ❑Subsidence Control
20 DRILLING LDG.9ttadi aditiuoal sheets if
❑Geothermal(Closed Loop) ❑Tracer P11'14q1
M TO DFSCRIPTIUN color,hardness,eoiUroctt m erg
❑Geothermal(Hearin Coolin Return ❑Other(explain under#21 Remarksrt 2 ft
tt �7t
4.Date Well(s)Completed: t Well 1D# 3.5 it t ft
Sa/.1Well Location: R f ft
l itr A-IS 11]Qi-A er) ft ft
Facility/Owner Name Facility lD#(if applicable) R !t
_TAdeptnd"Ce '[3ty ,SUjgnA4no9 219806 ft ft
Physical Address,City,and Zip 2L REMARKS
wncrnabe gl(abaNpl 190M
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: t
22 CerliReation:
(if wall field,one lat/long is sufficient)
ft
35-1
SifpatuWqXcrfificd Weu Con for
6.Is(art)the well(s): laK.-- ent or ❑Temporary
By slgrong this fornt,I hereby cemfy that 11x well(s)was(were)constructed in acawmlartrz
with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Wdl Cmstruction Standards and that a
7.Is this a repair to an existing well: ❑Yes or CHVo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction hfornration and esplain the nation of the
repair wider#21 renmks section or on the back of thisfonn 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 multiple injection or non-water supply wells ONLY with the same conatracliorr,yai can
sub„ut oreform SUBMITTAL INSTUCTIONS
9.Total well depth below land surface !6.5 (lit.) 24a. For AD Wells: Submit this form within 30 days of completion of well
For nmhtpk wells list all depths if diQerent(example-3@200'and 2@100� construction to the following:
10.Static water level below top of casing: SQ (ft) Division of W ater Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,RaleW NC 27699-1617
11.Borehole diameter: (in.) 24b.For Injection Wells. In addition to sending the form to the address m 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 folluv ing:
(i.e.auger,rotary,cable,direct push,etc.)
Division of water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-16M
13a.Yield )m Method of test: Blowing-Rig 24c.For Water So &Iniection Wells: In addition to sending the form to
(gp <�l the address(es) abe ve, also submit one copy of this form within 30 days of
13b.Disinfection type: Chlorine Amount: ��,OZ. completion of well construction to the county health department of the county
where constructed
Form OW-1 North Carolina Department of Environment and Natural Resources—DFvision of Water Quality Revised Jan.2013
I