GW1-2022-03921_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:
Bobby W. Potts FROM4R To DESCRIPTION
Well Contractor Name ft / ft
NCWC 2028-A rt 0 ft •
e i
NC Well Contractor Certification Number 15.OUTER CASING(for malti•eated.wdls OR LINER id ble
FROM TO I DIAMLrM THICKNESS MATERIAL
Ferguson's Well-and Pump, LLC 0ft ft _Y';­ 71101,
Company Name 16.E%iM CASING OR TUBIlVG.fg6odierind dosed
t FROM I TO I DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 35(a 3 cZ i ' ft ft ;R
List all applicable well construcuon pemuts(t.e.County,State,Variance,etc.)
ft ft in.
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE TMCIflVFS3 MATERIAL
❑Agricultural ❑M�unicipal/Public [t ft UL
❑Geothermal(Heating/Cooling Supply) 0<.dential Water Supply(single) ft it m'.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUTOIrrigation FROM TO MATERIAL P1elACEMENTMErHODaAMOUNT
Non-Water Supply Well: 0 ft 20 Concrete Gravity-Flow
❑Monitoring ❑Recovery ft [t
Injection Well: ft ft
❑Aquifer Recharge []Groundwater Remediation 19.SAND/GRAVEL PACK . e
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL I DeLACEME NT METHOD& ft!
❑Aquifer Test ❑Stormwater Drainage ft &
❑Experimental Technology ❑Subsidence Control
2&DRILLING LOG act ch addiigtW swats ff I
❑Geothermal(Clusud Loop) ❑Tracer FROM TO DESLIUMON color hardness,soiUrocif 47w,OrWn Aze,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) o
ft 0 .ft
av
rt ft.
4.Date Weil(s)Completed: Well ID/i ft It
Sa.Well Location: S ft ft / C
e
V(C_�Ur't.to C-liol-i'a & ft
Facilityf06crName Facility 1D#(if applicable) ft ft
' ce) (ZlAm.4cu Stye IS6rn l2 (�la
J i1.Jxi L.? ft ft
Physical Address,City,and Zip J 2L REMARKS W r 1
ion 14denbr 97614-(PI --/-F9 . �3 _
C9unty Parcel Identification No.(PIN) APR 12
mo
Sh.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certificad
(ifwcu ScK one latllong is sufficient)
�x n�1` ^Aa �ll�/id
(/ W �Y i:1 c v =, , 7�' aq':Un7 U\q
�� Si cure o ed Well fiat r
6.Is(are)the well(s): EWerrnanent or ❑Temporary
BY slgrang this form,I hereby certify that the well(s)was(were)corWrnncted in accordance
with ISA NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: Oyes or ❑K copy of this record has been providbd to the well owner.
If this is a repair,fill out brown well construction information and eVim the nature of the
repair under#21 ranarks section or on the back of thisfmm 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 wells constructed: oonstruction details. You may also attach additional pages if necessary.
For-111ple vyection or non-water supply wells ONLY with the sane eons4udiar you can
submit acre form SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 40 S • (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfdfferent(--nple-3(Qa 200'and 2@100') construction to the following:
10.Static water level below top of casing: ft) Division of Water Quality,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (in-) 24b.For Inieetion Wells: 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 construction method: ry construction to the following:
(i.e.sugar,rotary,cable,direct push,etc.)
DKIsion of Water Quality,Underground Injecdo*Control Prpgram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-16M
13a.Yidd(gpm) S Method of test: Blowing-Rig 24c For Water Supply&Iniectioa Wells: In addition to sending the form to
the address(es) above, also submit lone copy of this form within 30 days of
13h.Disinfection type: Chlorine Amount: 60 0Z. completion of well construction to the county health department of the county
where constructed.
Form G W-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013
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