GW1-2022-03978_Well Construction - GW1_20220412

WELL C:ONSTRUUTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts FROM 4 T DESCRIPTION
Well Contractor Name ft ft
NCWC 2028-A rt 3ad ft
NC Well Contractor Certification Number I&OUTERCASING ormdti•eatedwd6 OR LINER d
FROM TO DIAMETER TFUCKNESS 11L1I'F u—IL
Ferguson's Well and Pump, LLC �. z�
Company Name 16.INNER CASING OR TURINGtmeadurnul dosed400
F h FROM TO DIAMETER THICENFM MATERIAL
2.Well Construction Permit#: 2 o Z 1 - V 0 a-7.a ft ft in.
List all applicable well cautruction pe»rtitS fl.e.Coardy,State,Vartame;etc.)
ft ft m
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER: SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Muni ipal/Public ft ft in'
❑Geothermal(Heating/Cooling Supply) l�Itesidential Water Supply(single) R ft in
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18-GROUT _
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
01rhization 0 ft 20 ft Concrete Gravity-Flow
Non-Water Supply Well: ft ft
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GgAVIRL PACli. e
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL En>PLACEnEtvTnlgrxoD
ft ft
❑Aquifer Test ❑StormwaterDrainage R ft
❑Experimental Technology ❑Subsidence Control
Za.DRILLING LOG:attach'addithao:d rdseets if �
❑Geothermal(Closed Loup) ❑Tracer FROM To DESCTtEMON color hardn soitfrocit d2e,etc
❑Geothermal(Heatin Coohn Return) ❑Other(explain under#21 Remarks) 1 ft S13 ft lit
4.Date Well(s)Completed: �.2 Well IIJ# ft B ft R
ft. ft C
/p
Sa.Well Location: ft y ft W c
U 1 l n ft ft
Facility/Awner Name n /� Facility ID#(if applicable) ft ft
n
=1 �0r{G�)lSAn IG� 1 gYL lQt' oZt71r ft ft
Physical Address,City,and Zip r9
p 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification fi s „Y '
(ifwell field,one lat/long is sufficient) Jda i~ 31 M
/ r�r�� tl
� Sigffiture of fled W Con for to
6.Is(are)the well(s): QPermanent or ❑Temporary
By signing dais farm,I hereby certify that the well(s)was(were)constructed in accordance
�� with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Wdll Construction Standards and that a
7.Is this a repair to an existing well: ❑ LtYes or 1Vo copy of this record has been pt+vW&d to the well owner.
If this is a repair,Jill out known well construction hfon ration and explain the naho+e ofthe
repair rider#21 renmrb section or on the bacir of fi=fmm 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 maldple tryection or non-water supply wells ONLY with the same eansbuelion,you can
sub»di a w form // SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 3 yS (fL) 24a. For All Wells: Submit this',form within 30 days of completion of well
For multiple wells list all depths if aiff—t(—nple-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 2, A) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Marl Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (in-) 24b.For Iniection 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
1L Well construction method: ry construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injectioi&Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
Blowing-Rig24c.For Water Sunniv&lniecdoa Wells: in addition to sendingthe form to
13a Yield(gpm) Method of test: the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chlorine Amount.• 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—Division of Water Quality Revised Jan.2013
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