GW1-2022-06331_Well Construction - GW1_20220705

WELL UJINSIRUCTlON-RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts 14 WATER
FROM TO DESCRREMON
Well Contractor Name ft ft
e • .
NCWC 2028-A rt ft
NC Well Contractor CcRificationNumber IS.OUTER CASING ifermnitreaged.vd[d ORIUNER>f ble
FROM TO DIAMETER TMCKr'WM MATERIAL
00 Ferguson's Well and Pump, LLC ft. a K ft X.5: 2/ C S A&I
Company Name 1 INNER CASING OR TUI3EVG: dased4ou
Rl
.t / FROM TO DL►METER THICKNE4S MATERIAL
2.Well Construction Permit#: 0A a - d W IR ft ft m
List all applicable well construction pennits(i.e.Cotmty,State,P4riance,etc.)
ft ft in.
Well Use.(check well use): [FR
7 SCREEN
Water Supply Well: M TO I DIAMETER Sr oT C7P, I TH rww_44S I MATERL4L
❑Agricultural ❑M�ui�"pat/Public
ft ft in
❑Geothermal(Heating/Cooling Supply) QResidential Water Supply(single) n ft m
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT =
FROM TO MATERIAL EMPLACEME iTMEMOD&AMOUNT
01ni ation ft 20 ft. Concrete Gravity-Flow
Flow
Non-Water Supply Well: tY'
❑Monitoring ❑Recovcry ft ft
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACE.Of applicaNc)
FROM TO MATERIAL EMPLACEttff+Slfll=10D
❑Aquifer Storage and Recovery ❑Salinity Barrier- tt f£ s
❑Aquifer Test ❑Stomtwater Drainage ft, ft
❑Experimental Technology ❑Subsidence Control
20:'DRILLING LOG atrsdi•add:t'rmal sheets
❑Geothermal(Closed Loup) ❑Tracer FROM To DESCRIPTION color,hardness,sof ocir d2e,etz
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft ft
ft �
4.Date Well(s)Completed: Well 1D# ft2 ft
5a Well Location: & ft
Faci(rtyldtvner•Name Facility 1D#(if applicable) ft ft '+,•�-- ^-� r.°•'^° •, ""'"., r
L�5 Herron Ong -C J— weeftgt,uitte �Ss�B-� ft ft JUL Q
Physical Address,City,and Zip 2L REZLfAR$S
�tAy►-brAbe 1y l5515114 awv, ►n��;�' -: n �'�•
co7ty Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
INA
e aY F -9A" 3 3 A91 q 3 37. W ,Z
Signatureoftcr6W Well Contractor Dfite
6.Is(are)the well(s): a Cent or ❑Temporary By sigma this forn;I hereby certify that the well(s)was(were)constricted 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 o copy of this record has been provukd to the well owner.
If this is a repair,fr11 out brown well construction irrfornration and explain the nature,of the
repair wider#21 remarks section or on the bade of Lhisfoym 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 multiple iryection or nary-water supply wells ONLY with the same construction,you can
submit one form SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 3),S (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For mutiple wells list all depths if different(exmnple-3@200'and
72@!00') construction to the following:
10.Static water level below top of casing: t7�(/ (ft) 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 Injection Wells 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
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injections 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 Snon&&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.. 50 QZ, 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