GW1-2022-03916_Well Construction - GW1_20220412

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple welts
1.Well Contractor Information:
14.WATER ZONES
Bobby W. Potts PROM TO I DESCRIPTION
Well Contractor Name ft. so ft
NCWC 2028-A - ft ft
NC well Contractor Certification Number 11 OLrFM CASING d wefts OR LINER bit
FROM I TO DIAMETER THICKNESS MATERIAL
Ferguson's Well and Pump,,LLC & d. " 4- 1 PVC
company Now 16.INNER CASING OR G
FROM TO DIAtdL1FR THICKNESS MATFRTAL
z wen construction Permit#: Ell - ZZ t 17 ft ft 'is
List aQ applicable we0 canstrretion perndts(ce.Comity,State,Yadarce,etc.)
tc tt in.
3.Well Use(cheep well use): M SCREEN
Water Supply Well: FROM TO DIAME'LFR SLOT sue THICKNESS MATERIAL
❑Agricultural ❑ IpaUPublic ft ft hL
hL
❑Geothermal(Heating Cooling Supply) 91kesidcritial Water Supply(single) ft it
❑Industiial/Commercial ❑Residential Water Supply(shared) 'a.GROUT
FROM TO MATERIAL Ebffl ACP2dFN r MEfHOD&AMOUNT
Dhyiaation 0 ft' 20 ft Concrete Gravity-Flow
Non-Water Supply Well:
is [t
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 11 SAtVD/G1tAVEI.PACK
FROM TO I MATERIAL hfETHOD
❑Aquifer Storage and Recovery_ ❑Salinity Barrier &
❑Aquifer Test ❑Stormwater Drainage & ft
❑Experimental Technology ❑Subsidence Control
211 DRILLING LOG atta3t addltiaoal'e mb ff
❑ mutheamal(Clused Lu)p) ❑Tracer PROM I TO DFSLTIPI'tON color,hardn "Ursa ove,OMM die,etc
❑Geothermal(Heating)Cooling Return ❑Other(explain under#21 Remarks) R it 1
ft ft
a.Date Well(s)completed: � � Well IDg ft ft 1JejqtA0CC
SL Wen Location: 174X fc ft
-Do n.&.Sj.i�lt.r tl a saraj�� ft, ft
Facility/Owner Name Facility ID#(if applicable) ft ft
/9 r
taay L1(�f►�lvr�lfrn � Cb�ltMhVS 'o�57 ft ft
Physical Address,City,and Zip IL REMARKS
7P0l k tq,3
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficimt)
3s°(3:2gh d 17.2 t) N )o � ' �� fp�(a tr W
signature n e l well tractorWk
6.Is(are)the well(s): ermanent or ❑Tcmporary By ag mig this form,1 hereby oertify dial.the weA(s)was(were)constructed in accordance
� with 15A NCAC 02C.0100 or IJANCAC 02C.0200 Well Cmstructim Stmdan*and tier a
7.Is this a repair to an esisting wen: ❑Yes or 099 copy of d►ds neoordhas been provided to die well owner.
If this is a repair,fill ore known well corznr tot Obrnratiorr aid cWlam the mature of die
mgmr raider#21 rmarl s section or on the back o'dus farm 23.Site diagram or additional well details:
/ You may use the back of this page to provide additional well site details or well
S.Number of weal constructed: construction details. You may also attach additional pages if necessary
For rindaple tryecam or nowwaer supply wells Ohl with the sane canatruc6on you can SUBM11TAL INSTUCTIONS
sabv&out form
9.Total well depth below land surface: ��/5 qq 24a. For An Wells: Submit this form within 30 days of completion of well
For—Ample wells list ali depths if tV-w(etanple 3®200'and 2Qa 100') construction to the following:
10.Static water level below top of casing: ,TQ (it) Division of Water Quality,Information Processing Unit,
11 water level is about casing,use
'"l+" 1617 Mail Service Curter,Ralei&,NC 27699-1617
11.Borehole diameter: ' V (m) 24b.For Iniection Wens: In addition to sending the form to the address in 24.
Rota above, also submit a copy of this form within 30 days of completion of well
IL well emstruetiom method Rotary 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 AMService Cc nIte;;,Raleigh,NC 27699-1636
i
13L Yield((spin) Mid of teat
Blowing-Rig 24c.For Water Sumnly&IniectionlWdls: In addition to sending the form to
the address(es) above, also submit;one copy of this form within 30 days of
13b.Disintection type: Chlonne Amount:= oZ• completion of well construction to the county health department of the county
where constructed
*7—t.r,. i;r rLen t—t of Rmrimnment and Natural Resources—Division of water Quality Revised Jan.2013