GW1-2022-06330_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:
Bobby W. Potts 14.WATERZO
FROM TO I DESCRIPTION
Wcll Contractor Name fk 0 ft
NCWC 2028-A ft1Jx ft
NC Well Contractor Certification Number 15.OUTER CASING(for nrtnlli-caced.wdls OR LINER rt a able
FROM TO DIAMLrfER THICKNESS MATERIAL
Ferguson's Well and Pump, LLC fr. f — in. e-`
Company Name 16.INNER CASING OR TUBING 'wAbermal closed-lot
L/` / FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit 7 L ft ft in
List all applicable well construction penmits(i.e.Cowo,State,Variance,etc.)
M ft in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural Cn 1w� /Public ft ft
❑Geothermal(Heating/Cooling Supply) esrdential Water Supply(single) ft ft in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT _
FROM TO MATERIAL EMPLACEMM METHOD 3 AMOUNT
Non-Water Supply Well: 0 rc 20 ft Concrete Gravity-Flow❑Monitoring ❑Recovery it [t
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK,d.a ble
MATERW EMPLACEMFSTf ME THOD
❑Aquifer Storage and Recovery ❑salinity Barrier FROM TO
ft. � o
❑Aquifer Test ❑Stormwater-Drainage
ft ft
❑Experimental Technology ❑Subsidence Control p
20.DRILLING LOG:ittarliadditionaldwetsifnecess
❑Geuthermal(ClusvdLuup) ❑Tracer FROM TO DESCRIPITON color,hardness,soil/rock tyrpt,grain die,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) ft t D ft
/�
4.Date Well ( os)Completed:� oCr2 Well ID# r] ft ft
t/ C
5a.Well Location: / I ft , ft
,t.r STC I to Qopd ,.� ft ft
Fads ity/b6cr Name Facility ID#(if applicable) ft ft
r
K( 04 i h fZ J err yi c to 7319 ft ft
Physical City,and Zip
21.REMARKS.
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: in�C;,:; >� P is CL.:: .. -:
(if well ficK one lat/long is sufficient) 22.Certifi lion: ,�11or�ir'r5�)ti
1/Z `U4 r w / r
Si nature ofCp 'fled ell Contra&or - D
6.IS(are)the well(s): ertoanent or ❑Temporary By signing 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 21qo copy of this record has been provickd to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair wider 421 remarks section or on the back of thisform. 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 rVechon or non-water supply wells ONLY with the same construction,you can
subrndt one form n a SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if di(/erent(etmnple-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: 1 (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For lnee dm 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: ry construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injectiolt Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Blowing-Rig 24c.For Water Supply&Injection 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: V OZ. completion of well construction to the county health department of the county
where constructed.
Form C<W-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013