GW1-2021-02610_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:
M.
Bobby W. Potts FROM R TZ Ox/ DFBC WTION
Well Contractor Name ft �l/�
NCWC 2028-A fi` ft.
NC Well ContracWrCutificationNumber I&OUTERCASING otmultimedwells OR LINER tf file
FROM I TO DIAMLrIF.R IMCEMW MATERIAL
Ferguson's Well and Pump, LLC ` 2,16ftA5 11nowu
Company Name r, f /� 16 CASING OR TUBIDI
Ua I - Vd �s FROM TO DIANWrER THICKNESS MATERIAL
2.Well Construction Permit#: ft ft m.
List all applicable well construction penWis(r.e.Cowdy,State,Variance,etc.) ft ft in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM I TO I DIAMETER I SLOT SIZE I T'Slt3avFss MATERIAL
ft ft ioi
❑Agricultural ❑Mwu ' lic
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft in
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT..
FROM TO MATERIAL IMPL10EMIENPMEPHODdtAMOUNT
❑Irri lion 0 rt 20 ft Concrete Gravity-Flow
Non-Water Supply Well: ft. ft
OMonitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remcdiation 19.SAND/GRAYEI:PACK..Of e
FROM TO MATERIAL FINPLACEtvffiVfMETHOD
OAquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control
2Q DRILLM I DG.attatitt'addifiioml Adak if
❑Geothermal(Clustxl Luup) OTraoer FROM I To DESt3dKIO r cuior,hardn so UM& eta
❑Geothermal(Hearing/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft q0 ft
eav
C,/ ft S ft.4.Date Well(s)Completed:%�Well WN Sa 6f/�
115 ft ft. /'O
Sa.Well Location: ft. 605 ft ,
Ise % r ft ft
Facility/Owner Name Facility 11'3#(if applicable) �j ft ft "'
16"-
1qq ,)LAQ 'fa-r �1P1'Jtl 7ttI.P t�Q� / ft ft 1
Physical Address,City,and Zip 2L REMARKS
n�om.h e �17��I�8!Ly Ll(o �5`c`
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: i tt�
(if wcll field,one tat/long is sufficient)
I
35 a << �' N 51z°37(3?,, 7308 w zv
Sig;a1re ofg&fied Well Contractor ate
6.Is(are)the well(s): ermanent .or ❑Temporary By sigm tg this fo?M I A;';*oe.0 that die we (s)was(were)cmwucted m accordawe
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: oyes or o copy of this record has been provided to due well owner.
If this is a repair,Jill out bunco well eonsdvction information and explain the natroe of the
reppair:order#21 remarks section or on die bads of drisfonn 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.
For multiple iryec8ai or non-water supply wells ONLY with the sane construction,you can
submit oneform SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: LD_S (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
Fa muktple wells list all depths#drff-ent(eranple-3@200'and 2@100D construction to the folloming:
10.Static water level below top of casing. /0 (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. APA (in.) 24b.For Injection Wells In addition to sanding 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 follovang:
(i.e.auger,rotary,cable,direct push,etc.) i
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Matz Service Center,Raleigh,NC 27699-16M
13a.Yield(gpm) S Method of test: Blowing-Rig 24e.For Water Stir &Injection wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13L Disinfection type: Chlorine Amount: Q 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-4vision of Water Quality Revised Jan.2013