GW1-2022-10536_Well Construction - GW1_20221121

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
Bobby W. POttS 14.jK MAT$R.T2ANES F DESCRIPTION
Well Contractor Name rt ft
NCWC 2028-A ft ft
NC Well Contractor Certification Number 15.OUTERCASIIVG(formniticagedwe1k ORLINER 411 f ble
FROM I TO DIAMETER IMCKTIM 4 MATERIAL
Ferguson's Well and Pump, LLC 0 ft in, /25� 170PUD021
Company Name I&INNER CASING OR I G.4goodurmal elosed4on
f FROM TO DIAMETER TffiCENFM MATERIAL
2.Well Construction Permit#: ZaZ Z /�J ft ft in.
List all applicable well eorutruction permis(t.e.Cownty,State,Variance,etc.) ft ft in
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE TFHCKNM MATERIAL
❑Agricultural ❑ pal/Public ft ft in
❑Geothermal(Heating/Cooling Supply) 1 esidential Water Supply(single) ft ft in
❑Industrial/Commercial ❑Residential Water Supply(shared 18.GROPT
01trigation Q
FROM TO A MATERIAL EMPLACEMENTMETHODa.AMOM
Non-Water Supply wen: f` 20 fL Concrete Gravity-Flow
❑Monitoring ❑Recovery ft. ft
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remudiation 19.SAND/GRAVEL PACK qfflikablil
❑Aqu FROM TO MATERIAL EIPLACEME TT AiETHODifer Storage and Recovery ❑Salinity Barrier ft f
❑Aquifer Test ❑Stormwater Drainage h ft
❑Experimental Technology ❑Subsidence Control
26:DRILLING LOG attadi'addit;ooal sheets if r
❑Geothermal(CluselLuup) ❑Traucr FROM TO DULREMON color hardness,sodfroeu etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) I oft7-2 ftlav
ft ft
4.Date Well(s)Completed: O� Well ID# Q ft. ft �
Sa.Well Location: �/ R ft !ea W;hip
ft ft
Facnlityl0wner N Facility ID#(if applicable)
G ft ft x
'rh �iJ/fin SDna 1 eu A/44n �b 7W ft ft i~ ° r
Phvsical Address,City,and Zip
21.REMARKS
�i�n 4d2 _
Coun Parcel lEenfification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one latAong is sufficient)
�o �R: /s87� /N $ 3S 'Na '732'W :�" d
Si Certified Well Con for pace
6.Is(are)the well(s): Permanent or ❑Temporary
B3'sigrmng this farnr,I hereby certify that the weA(s)was(were)constnrcted in accordance
�� with 15A NCAC 02C.0100 or 15ANC4C 02C.020011'e/1 Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or C3IVo copy of this record has been prow&d to the well owner.
If Ats is a repair,fill out bawn well construction i►rfomotion and esplabr the nature ofthe
repair under#21 remarks section or on the back of dhisforrr. 23.Site diagram or additional wen 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 hyection or iron-water supply wells ONLY with the same you can
submit preform SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 7 d (tik) 24a. For All Wells: Submit this form-within 30 days of completion of well
For mukiple wells list all depths if drf jerent(eranple-3@200'atd 2@100� construction to the folloveing:
10.Static water level below top of casing: (� (ft) Division of W ater 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 Iniection Wells: In addition to sending the form to the address m 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 fullovting:
(i.e.auger,rotary,cable,direct push,etc.) i
Division of Water Quantp,Underground Lrjectiog Control Prpgram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
Blowing-Rig24c.For Water Srmoly At Iniection Wells: In addition to set the form to
13a.Yield(gpm) Method of test: �
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chlorine Amount: .50 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