GW1-2021-02596_Well Construction - GW1_20210809

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
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1.Well ContmcWr Information:
14.WATER ZONES
Bobby W. Potts FROM TO I DESCRIPTION
Well Contractor Name ft t% [t
NCWC 2028-A r` -1/1) f`
NC Well Contractor Certification Number 15.OUTER CASING or OR LINER if ble
FROM TO I THICE3WM MATERIAL
Ferguson's Well and Pump, LLC S rt E 1 Y. - Zf 2
Company Name 16.INNER CASING OR TUBING. dased-lou
1�
FROM TO R DiANMT THICKNESS MATERIAL
7-Well Construction Permit#: A PA I - b o 1 g 3 ft- R hL
List all applicable well construction perndts(i.e.Cowuy,State,varimre,etc) ft ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE TEi<CKNESS MATERL4L
'��_ � ft Ift
in
❑Agricultural [�VI>i ' ipaVPublic
❑Geothermal(Heating/Cooling Supply) �estdential Water Supply(single) ft im
❑lndustrial/Commercial ❑Residential Water Supply(shared) It GROUT
FROM I TO MATERUL DeLACIMNTMETHOD&AMOUNT
01ni ation 0 ft 20 ft Concrete Gravity-Flow
Non-Water Supply Well: ft. ft
❑Monitoring ❑Recovery
ft ft
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEI.PACK Of 211911c1dilA
FROM TO MATI?12TAL DeLACEhffM11W1'H0D
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG N2ttadradditional sheets tf
❑Geuthermal(Closed Luup) ❑Tracer y
TO DFALIU'PION color,hards soil/rock d2 dc.
❑Geothermal(Heating/CoolingReturn ❑Other(explain under 421 Remarks ft dAy
729
4.Date Well(s)Completed: Well ID# ft.
(f C
Sann.Well Location: ft [t wv
{
CA V,A e r&_ ft ft
Facility/Owner Name Facility ID#(if applicable) ft ft
56 1win Qlcagc LDrr Wcwucryfltt_ ag-78-7 ft ft �
Physical Address,City,and Zip 21.REMpgES
�wnc�ryl b� C1133►224 38 600
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutedseconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) '&/
�s 5,6 7 N A"Ma 4 g,ZRIA W
Si f ed Wet Con r ate
6.h(are)the well(s): 20ermenent or ❑Temporary By signing thus form,I hereby eerhfy that the well(s)was(were)constructed in accordance
�- with 15A 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 copy of this record has been prvv;&d to die well owner.
If this is a repair,fill out known well construction hformation and explabt the nanoe of die
repair wider#21 remarks section or on dm bade of this form. 23.Site diagram or additional well'Actails:
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.
For mulliple iryection or iron-water supply wells ONLY with the same construction,you can
submit oneform SUBMITTAL INSTUCTIONS
9.Total well depth below land surface• A/OS (tit) 24a. For All Wells: Submit this form within 30 days of completion of well
For rmthiple wells list all depdu if dfferent(exmnple-3Qa 200'and 2@100') construction to the following:
10.Static water level below top of casing: .50 (ft) Division of Water Quaky,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:��17 (in.) 24b.For Infection Webs: In addition to sending the form to the address in 24a
Rotas ry above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 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: 1636 Mail Service Center,Raleigh,NC 27699-16M
13a.Yield(gpm) 3 Method of test: Blowing-Rig 24c For Water Sn�nly&Iniection`Wells: 'In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection type: Chlorine Amounts 'y$ OZ. completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Dpvision of Water Qurality Revised Jan.2013