GW1-2021-02592_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:
It WATER ZONES
Bobby W. Potts FROM I TO DESCRWnON.
Well Contractor Name V
NCWC 2028-A ft 70 `t
NC Well Contractor Certification Number IS.OUTER CASING multi-cued wdis OR LIlYER bk
FROM TO DIAMETER: TffiCFrNrFSS MATERIAL
Ferguson's Well and Pump, LLC e. 76 ft. 6, "L
Company Name 16.INNER CASING OR TUBIIdG dried-
/ FROM TO DIAMLrTFR THiCIQVFSa MATERIAL
7-Well Construction Permit#: �G7 R R
List aAapplicable well construction perndis(ne.County,State,Variance,etc.) D, ft in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETIb SIOrS1ZE THICIQ�tFSS MATERIAL
ft ft
�
❑Agricultural ❑ lie
❑Geothermal(Heating/Cooling Supply) 26sidential Water Supply(single) ft tt
❑Industrial/Commercial ❑Residential Water Supply(shared) 18 GROUT
FROM I TO MATERIAL Et6L Ccnw T METHOD&AMOUNT
01rrigation 0 ft 20 ft Concrete Gravity-Flow
Non-Water Supply Well: ft ft
❑Monitoring . ❑Recovery
ft ft
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation lA SANDlGRAVEL PACK Of nolicaMe)
PROM TO MATERIAL EMPLACENUMMMOD
❑Aquifer Storage and Recovery ❑Salinity Barrier D, ft
❑Aquifer Test ❑Stormwater Drainage & it.
❑Experimental Technology ❑Subsidence Control 20 DRILLING LOG atrseh additional sheets if
❑ muthermal(Closed Loup) ❑Tracer FROM TO DPSt.PIMON color,hardn soturock etc
❑Geothermal(Heatin oolin Return) ❑Other(explain under N21 Remarks) 0 ft a tt
CIA t/
60 ft ft
4.Date Well(s)Completed:_ Well ID# ft. ft
C
5a.Well Location: 74 R ses ft C
(nSo» ft ft
Facility/Owner Name Facility M#(if applicable) h. ft
1
20,3 71;-)1-on All I?_► Le;c>4er ft ft
Physical Address,City,and Zip 21.REMARKS Q`O gGC
County Parcel Identification No.(PIN) 3' e
5b.Latitude and Longitude in degrees/minntes/sawnds or decimal degrees: 22.Certificad n - 4
(if well field,one lat/long is sufficient)
3, 7V6 N � '.� . $q3z ` W S.` n wall; tractoir
.
6.Is(are)die well(s): ert>mnent or ❑Temporary By siWmng this form,1 hereby certify that the wells)was(were)constructed in accordance
with I SA NCAC 02C.0100 or.15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ePlo copy of this record host been provided to the well owner.
If this is a repair,full out brown well construction b#bmwuion and explain ire nature of the 23.Site diagram or additionA well details:
repair under a21 rmark section or on else back ofthis fo ra
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 h#ecum or non-water supply wells ONLY with due same conowedon,you can SLTBAGWAL INSTUCTIONS
submdtorefom. e-
9.Total well depth below land surface: 3QJ (ft) 24a For All Wells: Submit this form within 30 days of completion of well
For nnnitiple wells list all depths!f drfferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 19 (ft) Division of Water Quality,Information Processing Unit,
If water level is above casting,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.13orehok diameter.
10 (m) 24b.For Iniecden Webs: 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
12.Well constiaetion method Rotary construction to the following:
I
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service C��enter,Rakigh,NC 27699-1636
Blowing-Rig 24e.For Water SaoDis&Injection Wells In addition to sending the form to
13a Yield(gpm) �� Method of test- the address(es) above, also submit'one copy of this form within 30 days of
Chlorine oz. completion of well construction to the county health department of the county
13b.Disinfection type: Amount: where constructed
AM Nat, 1 R�vmrccs—Division of Water OualiN Revised Jan.2013