GW1-2022-06313_Well Construction - GW1_20220705

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
BobbyW. Potts 14..WATERZARM.
FROM TO DESCRIPTION
Well Contractor Name ft ft
NCWC 2028-A ft d ft
NC Well Contractor Certification Number -
r 15.OUTER CASING(for multi-cased.wcDa OR LINER if ble
PROM TO DIAMETER THICICNM MATERIAL
Ferguson's Well and Pump, LLC f� in U'C Z
Company Name 16.INNER CASING OR TUBING; dosed-lou
DTAMElf3i THICKNESS
2.Well Construction Permit#: Zo20 v C)s� o FY20M TO ft.
MATERIAL
List all applicable well construction pennits(i.e.Coto*,State,-Variance,etc.)
ft ft
3.Well Use(check well use): L
17,SCREEN
Water Supply Well: FROM To DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural []t11�[u�n'cipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft in
❑Industrial/Commercial ❑Residential Water Supply(shared) `18.GROUT..
FROM TO MATERIAL EMPLACEMENT AEMOD&AMOUNT
❑hri ation 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/GRAVEL PACK e
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENTAMMODft ft°
❑Aquifer Test ❑Stornrwater Drainage ft ,
❑Experimental Technology ❑Subsidence Control r
2&:DRILLINGLOG ittKh'2dditmaa ihects.if
❑Geuthermal(Clused Luup) ❑Tracer FROM TO DESCZtHyifON color haMn sollhock si2 etc
❑Geothermal(Heating/CoolingReturn ❑Other(explain under 421 Remarks) ft ft CI 1
ft ft
4.Date Well(s)Completed: Well ID# fc ft /O
5a.Well Location: ft ft /Q(N ,t e
VI[rlk ft ft
Facility%Owner Name Facility ID#(if applicable)
& ft 9
�L[ r ice,Z 7 b y
I of `� ° a
�..
�ICtrS b 1 f a y� ,4nh e (I 1�� D r(f l� Z�7g ft ft
Physical Address,City,and Zip
—+� 21.REMARKS,.
G 7 3uy 3�&[(o In,c;,rzw;e�t ?r,•;.�,, i�Ril
CPuty Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
3s ° � W - N. 5A035(27t $8V " WhdA�Z /1-2
Si fC fied Well Caa tor-
6.Is(arc)the well(s): Zermancnt or ❑Temporary By Sze this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 010 copy of this record has been provtekd to the well owner.
If this is a repair,fill out known well construction h omunion and erplabn the naive of&
repair under#21 remarks section or on the back of thisforan. 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 muhiple hgection or non-water supply wells ONLY with the sane cornstruerian you can
sub»nit oneform SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: %(D� (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For mahnple wells list all depths if different(exanple-3 00'and 2@!00') construction to the following:
10.Static water level below top of casing: 60 (ft) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Matt 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
11 Well construction method: rY construction to the follotting:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground TnjectioRControl Pragram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) l Method of test: Blowing—Rig 24c.For Water Supply&Iniection Wells: In addition to sending the form to
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