GW1-2022-03914_Well Construction - GW1_20220412

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
114 ZONES
Bobby W. Potts FROM�T TOr T DnCRWrION
Well Contractor Name it. 0 ft
NCWC 2028-A ft . ?d
f.
NC Well Contractor Certification Number ' 15.OUTER CASiNG ormdfi-eared wells OR LINER d
FROM I TO I DIAML= I TIUCKNE4S I MATERIAL
Ferguson's Well and Pump, LLC 0 ft- -7 "` k/ 57 PVC S&2-1
Company Name 16.INNER CASING OR G.fewdutrtuall dosed-ioo
A FROM TO DIAMETER I IMCNNESS I MATERIAL
2.Well Construction Permit#: �. - as 117 ft ft is
List all applicable well construction pernuts te.Country,State,Vonance,etc.)
ft ft is
3.Well Use(check well ruse): 17 SCREEN
Water Supply Well: FRO TO DIAMETER SLOT SIZE THIC14VE4S MATERIAL
❑Agricultural ❑ cipal/Public ft ft
❑Geothermal(lieating/Cooling Supply) al Water Supply(single) ft ft of
❑Industnal/Commereial ❑Residential Water Supply(shared) 18,GROUT =
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Ini Warn 0 ft 20 f< Concrete Gravity-Flow
Non-Water Supply Wdl: ft ft
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK e
❑Aquifer Storage and Recovery ❑Salinity Burlier FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage ft
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach'addidouid sheets if
❑Gcuthtarnal(Clused Luup) ❑Tracer FROM TO DFSLIdMON color,Garda sWitrack pV,grala d2e,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 10 ft 7-2 ft
ft ft C
4.Date Weil(s)Completed �a Well m# ft [t C
Sa.Well Location: [t ft
ZlRn t, i lei 11.4.s.4rAb [t ft Vim`
Facility/Owner Ira-me Facility 1D#(if applicable) fL R
/ ft ft APR 12
Physical Address,City,and Zip 21.REMARKS
County Parcel Identification No. IN) -taJ s,tJ UNWT
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:(if well field,one lat/long is sufficient)
3S1'/3 '2,9j !> T1 N _�SJ� ab7 '�`/i?,l/0 t` w ZZ, b / h&&-
� Si lure of fed W Contrac r D
6.Is(art)the well(s): (rermanent or ❑Temporary
BY stg»ing this farm,I hereby cerofy' than the well(s)was(were)constructed to accordmrce
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 I9ell Construction Standmds and that a
7.Is this a repair to an existing well: ❑Yes or o copy of this record has been provi&d to the well owner:
If this is a repair,fill out brown well construction brfornralion and explain the nature of the
repair under#21 ranarks section or on the back of this form 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 iryechon or non-water supply wells ONLY with the same twnstrudiaa,you can
submit orre form SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: Li�/sS (ft.) 24a. For Ail Wells: Submit this.,form within 30 days of completion of well
For mul iple wells list all depths ii Wrent(erarnple- Qa 200'card 2©100') construction to the following:
�I Division of Water Quality,10.Static water level blow top of casing: YI/ (ft) Qtt ty,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Cmter,Raleigh,NC 27699-1617
11.Borehole diameter. (in) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Rotary above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ry construction to the foHoming:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground LtjectiogControl Pvvgram,
FOR WATER SUPPLY WELLS ONLY: 16M Mail Service Center,Raleigh,NC 27699-16M
Blowing-Rigc.For Water Sunnhi&Inieetionl Wells: In addition to sending 13a.Yield(gpm) Method of test: 24 ding the form to
the address(es) above, also submit 4one copy of this form within 30 days of
136.Disinfection type: Chlorine Amount: cU OZ. completion of well construction to ithe county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013