GW1-2022-06329_Well Construction - GW1_20220705

WELL CUNSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. PottS FROM R T7 O DESCRIPTION
Well Contractor Name ft �P�') ft
NCWC 2028-A ft ft
NC Well Contractor Certification Number 15.OUTER CASING formplti-cased wells)ORLIlVER d ble
I MATERIAL
Ferguson's Well and Pump, LLC ADM ft T ctS nIAMF� en. 2(�cRNEss
/ S 005 /��
Company Name 16.INNER CASING OR NG.fffeadrermal dosed-1
P / FROM. TO DIAMETER• THICJ0gM MATERIAL
2.Well Construction Permit#: ZO Zb G �� ft ft in
List all applicable well construction pen�nits g.e.County,State,%wiance,etc.)
ft ft in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SM THICENESS MATERIAL
❑Agricultural ❑ pal/Public ft ft in
❑Geothermal(Heating/Coohng Supply) al Water Supply(single) ft ft in
❑IndustrialiCommercial ❑Residential Water Supply(shared) 1&GROUT
FROM TO A MATERIAL EMPLACEMENT N=OD&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
FIyIPLdCEMFNTIIl11HOD
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL
❑Aquifer Test ❑Stormwater Drainage ft ft r
❑Experimental Technology ❑Subsidence Control P
2&DRILLING LOG:attIt&addiiinal dweb if
❑Creutttenmal(Clusctl Loop) ❑Tracer ;VC;
TO DFsclt>p1zoN cola rotas saturate etc
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under 421 Remarks) ft. ft C o1
ft.
Date Well(s)Completed: /� /� Well ID#
ft ( S ftSa Well Location: ft ft
r
lendi
w
f/1 S ft ft
Facilityldwner--Name FacilityM4(if applicable)
ft ft
ft ft
Physical Address,City,and Zip }��} /����� `
21.REMARKS. J
—�� 6,Hcgn&1 t GIGI�9�78(�Ci?e
Cpufety Parcel Identification No.(PIN)
56.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certifca' n:
(if well field,one Wong is sufficient)
35t1R1'3,A, S YtYIv �'.���2 '/ ?17/ w
Si f cd n tar D to
6.Is(are)the well(s): e'Permaaent or ❑Temporary
By signing this form,I hereby eerSfy that the well(s)was(were)constrtreted in accordmrce
_/ 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 �1Vo copy of this record has been provi&d to the well owner.
If this is a repair,fill out known well construction information and explain the nahne ofthe
repair under 921 rwwrks section or on the back of ditisfmm 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 multiple oyeetion or non-water supply wells OATY with the same consstrudion,you can
subtut oneform SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 3!S (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For muhple wells list all depths if different(exmnple-3Q200'and 2@100') construction to the following:
10.Static water level below top of casing: r, A) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Matz Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection 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
12 Well construction method: Rotary construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground InjectioY&Control Pwgram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
Blowing-Rig24c.For Water Supply&Iniection Wells: In addition to sendingthe-form to
13a.Yield(gpm) Method of test:13b.Disin fection The address(es) above, also submit one copy of this form within 30 days of
Amount:
type: Chlorine V OZ. completion of well construction to the county health department of the county
where constructed.
Form CAW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013