GW1-2022-03988_Well Construction - GW1_20220412

WELL CONSTRUCTION RECORD For lntemal Use ONLY:
Tbis form can be used for single or multiple wells
1.well Contractor Information:
Bobby W. Potts AM TO// n>�cR»1Texv
Wall ConuadorName - R /t� f
NCWC 2028-A " ft
NC well Cootraetor certification Number I&0UI'ER M mad am
FROM ro MAXI M T—=--S MATERIAL
Ferguson's Well and Pump,,LLC d r ;hL 12 C 5 PAW
Company Name 14 RW=CASIPIG 0RTl WG
PROM TO DIAIdET1t1t I MAT1+TtrAL
2.well Coustrnetion Permit#• t9 6l 11— 0 b (a ft ft.
List aU applicable wel✓epstruedon pernats tie Coo*,Score.VWtff cg ;Ic) R ttbL
3.Well Use(check well use): 17.SCREEN
Water Supply Well: mom To DL►MEta� ,R r tt= reictavEss MATFRrAL
ft ft in,
❑Agneultural ❑ �'❑G ft ft
eothermal(Heating/Cooling Supply) tiai water Supply(ale)
❑IndustriaUCommereial ❑Residential water Supply(shaicd) 11 GP-OUT =
PROM I TO MATERIAL WMD&AMOUNT
OIrrigation 0 n" 20 rt Concrete GravPty-FIoW
Nan-water supply Wen: ft ft
❑Monitoring ❑Recovery
Injection wen: D f
❑Aquifer Recharge ❑Groundwater Remediation 1)94PODAGRAVEL PACK Or 210111colde)
FROM TO I MATERIAL ?JVMD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft
❑Aquifer Text OStotmwater Drainage ft.
❑ExperimentalTechnology DSubsidanceControl DRII�WNGLAG attadhadiliramdsiheeieit r'
❑Gevtlimmal(Closed Loop) ❑Trager PROM To DEscRmTTtxv tutor taraa mwrow etc
❑Geothermal(Hen Rettan DOther lain undo#21 Remarks C) & Q ft 1
ft ft
a.Date Well(s)Completed: well IN ft
20 c
Sa.Well Location: ft VS & e
'Sle l� cn 1:1r ft ft
Facility/Owner Name // __ Facility MN(if applicable) ft ft
1,05 C/4/.��/ l�I/� �C 4efig a.S�t a d' 8 740 fL ft A (�
Physical Address,City,and ZAP 21.REDfARKS
,� Cnmbe !R-M t 2Gua9g APR 12 _
Covnty Parcel I4eidi5eationNo.(PIN)
5b.Latitude and Longitude in degree mduntedswonda or decimal degrees: 21 CertiHcadon: +t 1101 Rf OCESSfIu UNU
(if well field,one IalAons is sufficient) i
;s 3f #y'737/21 N '91,y�/� " w
S of ed well Con
6.Is(are)the well(s): 2Permonent or Mcinporary By stgurg dds fom I hereby oa*dean dr wg(s)was(wtme)eoriosicied in occonbw
wilt ISANCAC 02C.0100 or 15ANCAC 02C.0200 We l ConsarseaimSrmrdan*and dw a
7.Is thb a repair to an e*ft web: OYex or 099 ropy ofdrys record has bear provided to die ve U owner.
If dds is a nepofr,fdl ow bacon well copmrucbm Wo►madon and arplabi die naft-Of die
mpmr w der#21 ry aarkr section or wr d e bank of dusfomn 23.Site diag min or additional well details:
/ You may use the back of this page to provide additional Well site details or well
8 Nunrber of vela constructed construedion details. You may also attach additional Pages if nexessM3
For mubpfe gecdaa or rear-water supply wells OMYwide dr same corer W&M,You can SUBr#I TAL INSTIICTIONS
subv&arxfarna
9.Total well depth below land surface: (tl:) U . For An Wdb Submit this form within 30 days of completion of well
For mukpk was Iw aU dWdis try(aaar k-3@M'and 2®1001 construction to the following:
Dividen of Water Quality,Information Proeesdag Unit,
10.Static water keel below top of casing ( ) 1617 M28 Serviee Center,Rakigah,NC 27699-1617
If water kwIls abm eadng,rue''``+„
11.Borehole diameter. U (m) 24b.For Inigg fM Wells: In addition to sending the form to the address m 24a
Rota above, also submit a copy of this form within 30 days of completion of well
1L Well W a nsnucti .&od: Rotary construction to the following: i
(i.e.anger,rotary,cable.direct push,etc.) Division of Water Quality,Underground Injoedon Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Man ServiceCenter,Raki&,NC 27699-1636
13a Yield(PM) Method oitest Blowing-Rig 24e.For water swift&BdectimVells• In addition to sending the form to
the addreas(es) above, also submit lone copy of this foam within 30 days of
13b.Diaiatexdon type: Chlorine - Amount: ; SQ OZ. completion of a constraotiem to the county health department of the county
I where
ructed.
*T. t%r•..,n-nu ftmwnt of F.mrimnment and Natmal Rcsomces-Division of water Quality Revised Jan.2013