GW1-2022-06323_Well Construction - GW1_20220705

WELL CONSTRUCTION RECORD For lntemal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts FROM R TO
DESCRIPITON
Well Contractor Name , ft. 9 R
NCWC 2028-A ft Md ft
NC Well Contractor Certification Number 0 15.OUTER CASING for multi-eated.wells OR LINER d ble
FROM TO DIAMPM I THICKNESS MATERIAL
Ferguson's Well and Pump, LLC ft ft- rvt i- f^
Company Name //�� ] �T e. 16.INNER CASING OR TUBING dosed-lac
le ( 1✓01 ! - UV G7 c FROM TO DUMEM. THICKNESS MATERIAL
2.Well Construction Permit#: 'ft ft in
List all applicable well construction permits(i e.Coiorty,'State,Yarrmnce,etc.)-
ft ft in
3.Well Use(check well use): 17,SCREEN
Water Supply Well: FR M TO DIAMETER SLOT SSMEE THICKNESS MATERLAL
❑Agricultural ❑ blic ft ft is
❑Geothermal Supply) esi�Water Supply(single) ft ft in
(Heating/Cooling PP Y) uPP Y( gl)
❑Industrial/Commercial ❑Residential Water Supply(shared) 1&.GROUT.. _
FROM TO < MATERL4L EMPLACEMM AiMOD dl AMOUNT
❑Irri ation 0 ft 20 ft Concrete Gravity-Flow
Non-Water Supply Well:
it ft.❑Monitoring ❑Recovery
Injection Wen: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK e
FROM TO MATERIAL E MPLACEMENCALEIfiOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft fc a
❑Aquifer Test ❑Stormwater Drainage
ft ft
❑Experimental Technology ❑Subsidence Control s
21C DR1LL1fIG LOG:attldi'additmasl shots if
❑Geuthermal(Closed Luup) ❑Tracer FROM I TO DESCRIPITON color,hardo soll/roclt A2e,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) C2
ft 0 .ft .V
ft. S ft
Or-Pt
4.Date Wells)Completed: Well ID# O(2 ft /C
Sa-Well Location: /f il) fc It G
NS� (2rt QLr-k c 5 O I,e�ts1ve�tAl k V
Facility%Omner-N _ ft ft
Facility ID#(ifapplicable)
►-{ TCtn.MU IZ��1 (�lclu t Iximuotitl<< ��a181 ft ft JUL Q 2022
r�
Physical Address,City, d Zip
REMARKS Zl. ..
COwl(o e l^ii�q i�5a Mii
�
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Ce on•
(dwell field,one lat/long is sufficient)
So�(3t a$ ti d3 y'f��lL Oaf—W / a•2
Sig6aturgofP&tificd Well Contractor ate
6.Is(are)the Well(s): Permanent or ❑Temporary By signbg this farm,I hereby certify that the weA(s)was(were)constructed in accordmnce
� with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Wdl Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or oM copy of this record has been pmvi kd to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair rider#21 remarks section or on the back of this form. 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: / construction details. You may also attach additional pages if necessary.
For rmdliple agection or non-water supply wells ONLY with the same construcrion,you can
submit one form SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: ,:2 6 S (fL) 24a. For An Wells: Submit this form within 30 days of completion of well
For muhtple wells list all depths if different(exwnple-3@200'and 2@1001) construction to the following:
10.Static water level below top of casing: ( O (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,we"+" 1617 Mail Service Center,Raleigh,NC.27699-1617
11.Borehole diameter. (in-) 24b-For Injection Wellst 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.auger,rotary,cable,direct push,etc.)
Division of Water Quanty,Underground Injection Control Program, .
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 0 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 the
�rj OZ. completion of well construction to the county health department of the county
where constructed.
Form C W-I •. North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013