GW1-2022-03989_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 1 �,TERzoNEsAtom TO
DEsttzoN
Wen Contractor Name R ft
NCWC 2028-A ft ft
NC Well Contractor Certification Number I.OUTER CASING welts
FROM TO DJAIMTER TffiCMKM S I MATERIAL
Ferguson's Well and Pump, LLC ( S'; 2/ i r4 S
Cry Nam s 16 CABIltIG OR
FROM TO DWd�1FR TffiC�iffi6 MATERIAL
L well Construction Permat M. a d a l ' d y 5-1•5 ft fL ;d
Litt aAappfieable well ca utrucdon permits(ee.Comity,Start,Yaifmrcg etc.) R ft
3.Well Use(check well use): 17.SCREEN
Water Supply WeD: FROM To DL4XZ t star SM MUC>.av> s MATIItiAL
ft ft in.
❑Agricultural ❑�pal/Public
❑Geothermal(HeatinlyiCooling Supply) r�Itesidential Water Supply(single) ft. m
❑IndustriaUCotnmercial ❑Residential Water Supply(shared) 18 GROUT _
FROM TO MATERtAI. 8 AMOUNT
0hrigation 0 a• 20 fr• Concretes Gravity-Flow
Non-Water Supply Well: ft ft
❑Moratming ❑Recovery
Injection well: n ft
❑Aquifer Rcchargc ❑Groundwater Remediation i%sANDAGRAVEL PACK
FROM TO MATERIAL I EWPLACEMEaNZMD
❑Aquifer Storage and Recovery ❑Salinity Barrier g, fc
❑Aquifer Test ❑Stormwater Drainage R, ft
❑Experimental Technology ❑Subsidence Control 2L DRUJMG LOG a" o d dreets if /
❑Geuthcrmai(Closets Luop) ❑Tracer MUM TO DEkMWnON odor,bsrde unksctt pj%smin dae,etc
❑Geothermal eatin Ronan ❑Other(explain under#21 Remarks) 9R s 0 ft
4.Date Well(s)Completed: �.�well MH 0 ft. S f
5 ft a ft <
St.Well Location: ft ft 1M
-Ke-nnelk Crtalnh ft ft.
Facility/Owner Name Facility ID#(if applicable) M ft
ffieo(.nr14Cr- l n rc6I r r)UC Q IfUlm] ft. _
Physical Address,City,and Zip 2L REMARKS
al,VQ0mbe- �c�asss-� ►era
County PwwlIdentiScationNo.(PIN) �!
r i mi a { 1��7ti �J
Sb.Latitude and Longitude in degeealndonte's/seoends or dedmal degrees: 22.Cerdlicatlon: �
(ifwell field,we latllong is sufficient)
SigmNm of eel Wall
fi Ts(are)the weIl(a): CrmaDeIIt- or ❑Temporary By sfgrrotg des farm,I hereby corny dW de weft)was(were)cansm¢tad in accord—
/ wi&15A NCAC 02C.0100 or ISANCAC 02C.0200 we l Congo wfim Stardmrk and dial a
7.Is this a repair to an casting well: ❑Yea or 014 copy ofdds record has been provided to dw' wA owner.
If dds it a repay fell ore baawn well cousovcdon iron tarion and aplain die nature of d►e
repair realer#21 rmafrs section or on die back of ddsform You
m diagram e a additional well d provi
you may use the back of this page to provide additional well site details or well
S.Number of wells constructed: construction details. You may also attach additional pages if necessary'.
For Muldple tryechm or nar water snppJy wells OMF m*dm same oora ieliar you can gUBMTITAL E%TUCTIONS
siibnst ale fans
9.Total well depth blow land smrface: Ll��s _(it.) 24a For All Wells: Submit this form within 30 days of completion of well
ell
wells ho aAdepdu if (haapk- 'and 2@1001 construction to the following:
Division of Water Quality,Informttiion Processing Unit,
IJ
f Static water level below top of casing ( )water level is aback casakg,use
''.`+" 1617 Mao Service Ginter, ,NC 2769961617
11.Borehole diameter. 10 (m.) 24b.For Injection Wens: 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
IL well construetlim method: ry construction to the following: t
(i.e.auger,rotary,cable,direct push,etc.) Injection Control
Division of Water Quality,Underground I Program,
FOR WATER 5UPPLY WELLS ONLY: 1636 man Service Center,RaWgb,NC 27699-1636
Yield m ,3 11 od ottesb Blowing-Rig 24-For Water swift dt hdoc"Wells: ]n addition to sending the form to
13a
(€P ) the addresses) above, also submit l one copy of this form within,30 days of
Chlorine �g OZ. completion of well construction to'the county health department of the county
13b.Disinfection type: Air where constructers.
re...i:..e T b—,t—i of Fmrimnment and Natural Resourtus-Division of water Quality Revised Jan.2013