GW1-2022-06352_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 FROM
TO DFtflriTON
Well Contractor Name ft J�+ ft
r o t
NCWC 2028-A ft ft
n
NC Well Contractor Certification Number a 1&OUTERCASING ormuld-cosedwells OR LINER(if
FROM i0 DTeMPTa'R THirrrratrcc MATERIALFerguson's Well and Pump, LLC tt S% & A5
in c
Company Name 16.INNER CASING OR TUBING dased4
L 152 FROM TO D1A110 M- THICKNESS MATERIAL
2.Well Construction Permit#: L 7 'ft. ft in
List all applicable well construction pets its(i:'e.Cowo,State,'Varimrcg etc.)'
ft & in
3.Well Use(check well use): 17 SCREEN
Wa't"upply Well: FROM TO DL41MM SLOT SS12E TFIECE iES3 MATERILAL
Cl/Agricultural ❑Mtuticipal/Public ft ft in
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft iR
❑Industrial/Commercial ❑Residential Water Supply(shared) 18*GROUT
FROM TO a MATERIAL EMPLACEMZN'TN=01)&AMOUNT
❑Im ahon 11 20 Concrete Gravity-Flow
Flow
0 ty_
Non-Water Supply Well: ft. ft
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAYIiL PACKfif M30111caulel
FROM TO I MATERIAL EMPLACEMENT MEMOD
❑Aquifer Storage and Recovery ❑Salinity Barrier R R
❑Aquifer Test ❑Stormwater Drainage R ft
❑Experimental Technology ❑Subsidence Control e
.2d DREU 1NG LOG.ittuh adiitlaoal sheets if
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCREPTiON color hardness,sattrro it grain size,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0ft. ft
Y64 ft ft
4.Date Well(s)Completed: Well ID# S ft ft
- Well Location: ft ft
e .
ft &
FacilAyid,vner N Facility ID#(if applicable) ft ft .
/U_W_ �� f�nLlI�IIA_ ft ft • `••.�
Physical A`dddre%City,*aad Zip 21 REMARKS- — %.� `�. �z S V
rM
A i ov—, S L g 3�B.nR� n ?
Cpuaty Parcel Identification No.(PIN) V
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: ^tst
22.CerliScation:
(ifwell field,one lat/long is sufficient)
Sd ( rr N � �tr / �i /�fy W
Signature of ed Well t6olfQtor
6.Is(are)the wcll(s): ermancnt or ❑Temporary By signing dris fornn&1 mil,cerfy drat the well(s)was(were)constructed in accordmrce
with 15ANCAC 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 provided to the well owner.
Ifthis is a repair,fill out biro m well construction information and erpl=the nature ofthe
repair wider#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 m ulhple irty'ectioi or not-water supply wells ONLY with the same construdian you can
subnt one fora SUBMITTAL INSTUMONS
9.Total well depth below land surface: ka (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For nutldple wells list all depths if a5ffere nt(ezmnple-3Q200'and 2Q100) 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 Marl 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 Rota 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 InjectiewControl Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-16M
13a.Yield(pin) S Method of test-.-Blowing-Rig— 24c.For Water Supply&Ittiection*ells: 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 S�7 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
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