GW1-2022-10522_Well Construction - GW1_20221121

WELL UUNSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts 114L.WATE1t7ANFS
PROM TO DESCRIPTION
Well Contractor Name ft ft f
NCWC 2028-A & ft j
NC Well Contractor Certification Number 15.OUTER CASING or mdfi-cared trills OR LINBRffif
FROM TO DIAMETER THICKNESS I MATERIAL
Ferguson's Well and Pump, LLC ft. n "Lly h-
Company Name 16. CAS1NG OR G.
FROM TO DIAM_Iia THICKNESS MATERIAL
2.WeD Construction Permit#: !,►,� ��!�� ETERft ft in.
List all applicable weft construction pemrits 0 e Cotaik State,'Yanmrce,etc.)
tL ft in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE TEUCKNM MATERLAL
❑ cultural ft ft in.
❑ cipal/Public
❑Geothermal(Heating/Cooling Supply) fdResidential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT _
FROM I TO MATERIAL DeI ACEMIIM METHOD&AMOUNT
❑Irrt ft 20 ft Concrete Gravity-Flow
Non-Water Supply Well: �
❑Monitoring ❑Recovery
ft. ft
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVELPACKfig.mpididmIld..'a
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATMAL I EMPLACEMFNTMEMOD
ft t£
❑Aquit'er Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control R ft r
20 DRI IMG LOG_attach addlti�a`aets ff
❑Geothermal(Closed Loup) ❑Tracks FROM To DESt3WnON cdor,hardn sduroclt etc
❑Geothermal(Heatin oolin Return ❑Other(explain under#21 Remarks ft ft 1
�� ft 3s ft
tay
4.Date Wells)Completed: /,�;y�Well IDq
/ ft y ft
Sa.WellLocation: Ac
111R ft C
h & ft
acility1dwnerName Facility EX(if applicable)
ft ft
8 ft. ft t
Physical Address,City,and Zip
2L REMARKS .111
Coun Parcel Identification No.(PIN)
wflf>a-•ation, pr.�cg Unil
56.Latitude and Longitude in degreeshminutes/seconds or decimal degrees: 22 Ce ti :
(ifwell field,one lai/long is sufficient)
s° tl B r�� .1 rN B.2°�.S�S�_4/e W4 R
�� ' Signature of Wel Contracto
6.Is(are)the we l(s): IQ crmauent or ❑Temporary By sigrm,g this forM 1 hereby cer*that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 o-15ANCAC 02C.0200 Wd l Construction Standards and that a
7.Is this a repair to an ei isting well: ❑Yes or o copy a f this record hares been provt&d to the well owner.
If this is a repacr,,Jill out known well construction v&fmnalion and explain the nature ofdoe i
repair under 921 rmtarks section oron 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 nv Wple iryection or non-water supply wells ONLY with the sane antssduadion you can
submit a�farn SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 2—s- 00 24a. For All Wells: Submit this form within 30 days of completion of well
For madttple wells list all depths if dr,(jerent(aranple-3@200'and 2@1001) construction to the following:
10.Static water level below top of casing: f0 (ft,) Division of Water Quality;Information Processing Unit,
If water level is above casrng,use"+" 1617 Matz Service Center,Raleigh,NC 276994617
11.Borehole diameter. (m_) 24b.For Inieeden 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
11 Well construction method: Rotary construction to the following:
(i.e.auger,rotary,cable,direct push,etc.).
Division of Water Quality,Underground Injection Control PrPgram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mangy Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Blowing-Rig 24c.For Water Supply&Iniection 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: e7�i 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