GW1-2021-02590_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:
Bobby W. Potts FROM4 TOE DESCRIM-0-N
Well Contractor Name ft gig &
NCWC 2028-A ft ft
NC Well Contractor Certification Number 15.OUTER CASING wells OR LINER rf
er multi-eatedl ble
FROM I TO DIAMETER I THICKNESS I MATERIAL
Ferguson's Well and Pump, LLC ft. I ft.
Company Name
16.INNER CASING OR TUBI_G: dosed
Z y2 � -U PV G�� FROM � TO R DIAMETER� THICKNF.44 MATERIAL
L Well Construction Permit#:
List all applicable well eonsinwifon permits(Le.County,State,Variance,etc.) ft, ft is
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMEIFR SLOT SIZE THIC[tNFS3 MATIZtL4L
ft ft m'
[]Agricultural CnF�ut�a1/Pttblic
❑Geothermal(Heating/Cooling Supply) esrdential Water Supply(single) n ft.
❑Industrial/Commercial ❑Residential Water Supply(shared) .18.GROUT
FROM TO MATERIAL EMK ACEI M%rr?ArMOD&AMOUNT
❑Irri anon 0 rc 20 ft Concrete Gravity-Flow
Non-Water Supply Well: ft. ft
❑Monitoring ❑Recovery
Injection wen: ft ft
❑Aquifer Recharge ❑Groundwater Remediatiou 19.SAND/GRAVEL PACK Of e
FROM TO I MATERIAL I EMPLACEMENTAWMOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft &
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control
Tb:DRILLING LOG.attacti ad&Gmal weds
❑Geuthermal(Closed Loup) ❑Traccr ;'0'
M TO DESCItIMON color,hardy sdUrock m etc
❑Geothermal(Heatin lire Return ❑Other(explain under 421 Remarks0 ft f ft (
FL ft
4.Date Wens)Completed: ► / Well T>3# ss� ft K
S/a.I-W-eII Location: �•- f r l r is ft f G
ft. ft �►
Faulity/Owner Name Facility ID#(if applicable) n
(°92 Qee.m.S Cree 4 WlrAuorvifl 2$781 ft it T
Physical Address,City,and Zip 2L REMARKS
�5
r
County _ Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well Scld,one lat/long is sufficient) 2L Cermtfflccatio t<ry� Q
w
Signature o Well&nlbd&
6.Is(ate)the Well(s): �ermmcnt or ❑Temporary4*L
By signing this form;I�reby eer*ddat the well(s)was(were)constructed in accon*nw
with ISA NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an ezistmg well: ❑Yes or 2 o copy of this record has been provided to doe well owner.
If this is a repair,Jill out brown well conouctron bi onna7ion and explain the nature of the
repair under#21 remarks section or on the bade of zkyfmin 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: l construction details. You may also attach additional pages if necessary.
For multiple byection ornon-water supply wells ONLY with the sane coraouchon,you can
submit ayeformi, SUBMITTAL INSTUCTIONS
9.Total wen depth below land surface: 2 2 J (t}) 24a. For All Wells: Submit this firm within 30 days of completion of well
For nuddiple wells list all depdu if df'er nt(ecanple-3@200'and 2QI00') construction to the following:
10.Static water keel below top of casing: 719 (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 120 24b.For Infection We%: 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
17-Well constrtction method: Rotary wnstnu:tion to the folluaing:
(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 27699-1636
13a.Yield(gpm) Blowing-Riglac.For Water &In'ectionl Wells:'In addition to sending the form to
3� Method of test the address(es) 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-4vision of Water Quality Revised Jan.2013
I