GW1-2022-06349_Well Construction - GW1_20220705

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple w4s
1.Well Contractor Information:
Bobby W. Potts FR MAC TO I DESCRWHON
Well Contractor Name ft ft
NCWC 2028-A = ft ft
NC Well Contractor Certification Number IS.OUTER CASING(for m••ld�iscil.yells ORLINER diff bk
FROM TO I DJANRATRr2 I THICKNESS MATER1pL
Ferguson's Well and Pump, LLC a ft / It i- Iqg �-e
Company Name 16. ER CASING OR TUBING. thermal closed-lot
/� ,1 FROM TO DIAMETEtt THICKNESS MATERIAL
L Well Construction Permit 66 too D 3 V ft ft in
List all applicable well construction permits(i.e.County,State,Varrm'^rc e,etc.)
ft ft in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM To DIANCMTR SLOT SIZE THI00TEM MATERIAL
❑Agricultural ❑ blic ft ft in.
❑Geothermal(TIeating/Coohng Supply) esideatial Water Supply(single) ft ft in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERILAL EMPLACMMZNTA�TITOD 8.AMOUNT
Non-Water Supply Well:
[]Irrigation 0 ft. 20 ft Concrete Gravity-Flow[]Monitoring ❑Recovery ft ft
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK, e
FROM TO MATERIAL EMPLACEMFIS'f➢MOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft:
❑Aquifer Test ❑Stormwater Drainage
ft ft
❑Experimental Technology ❑Subsidence Control
la.DRILLING LOG:att Kh additionA sheets if
❑Geothermal(Closed Loup) ❑Traux FROM I TO DESLP1PTI0N color,hardnas,sofVrock n A2e,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) d ft
4.Date Well(s)Completed: Well ID# S ft fG ft S !`
ft 2 / ft
SaTWell Location: c f ( ft fI,,,�� L
n t JYYI ft ft '- y
T�� µ C
Facility(Owaer Name Facility IL?k(if applicable) .ft ft lx •A i,—"s
(70 n) / re U1e_Gl 4&he fn&g=nud (Q OR ft ft
Physical Address,City,and Zip m
�
I 7 Q�( 21.REhfARKS�CtYIdG/SIJh df00.3g 986s y r,! n P . r4r
r:� <'X=J
County 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:
S° �7 3z /7 't N R.-1/6 t6/ �,�.� W _> / /Z/
Sigrdture a Ccrtis We n r'- re
6.Is(are)thewell(s): QPermanent or ❑Temporary
By signing this form,I hereby certify than the wells)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 o copy of this record has been provi&d to the well owner.
If this is a repair,fill out known well construction h#bmration and explain the nature of the
repair under 421 rerrrarks 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 nwltiple injection or non-water supply wells ONLY with the same construedon,you can
subunit one forme SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 411) (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For nwhiple wells list all depths ifditfferwt(example-3 200'and 2@!00') construction to the following:
10.Static water level below top of casing. (ft) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Abil Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 241b.For Injection 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 Injection;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: Chloride Amount: �5­67 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