GW1-2022-10538_Well Construction - GW1_20221121

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobb W. Potts 14.WATERZONES
Y FROM TO IP17 DESCR0N
Well Contractor Name fi ft
NCWC 2028-A ft ft
NC Well Contractor Certification Number 15.OUTER ASING form ti--edwas OR LINER da cable
FROM TO DIAMETER nucim SS MATERIAL
Ferguson's Well and Pump, LLC ft ft 114 CS 2
Company Name 16 ER CASING OR TURING_f9eadmuA dosed ou
FROM TO llIAMETIIt THICKNESS MATERIAL
2.Well Construction Permit#: _0 Z Q G t7 LL ft ft in
List all applicable well construction permits(r.e.County,State,Variance,etc.)
R ft in
3.Well Use(check well use): 1%SCREEN
Water Supply Well: FROM To I DIAMETER SLOT SIZE I TFUCKvFss I MATERIAL
❑Agricultural ❑� pal/Public ft ft in
❑Geothermal(Heating/Cooling Supply) fdResidential Water Supply(single) ft ft in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
[]Irrigation Q
FROM TO MATERIAL EMPLACEMENT RMTHOD&AMOUNT
Non-Water Supply Well: ft. 20 It Concrete Gravity-Flow
ft ft
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediatiou 19.SAND/GRAVEL PACK flif a e
FROM TO MATERIAL EMPLACEMENTAWIHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft:
❑Aquifer Test ❑Stormwater Drainage & ft
i
❑Experimental Technology ❑Subsidence Control X DRILLING LOG tattach additia®al sheets if /
❑Geuthermal(Closed Loup) ❑Tracer FROM TO DESCRII 1TON color hardneu,soitIMIL a dze,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) / ft /_ ft /Z
ft ft �e
4.Date Well(s)Completed: Well ID# S ft th/ ft
Sa �c /'aC Well Location: ft ft FQ
TRF) 1z4=j 1l.0P_— ft ft
Faraity/ wnerName Facility ID#(if applicable) e �
/f ft ft e i V
v C287/S ft ft
Physical Address,City,and Zip 21.REMARKS
r4,orcraUan'PrznW0ir9 UrQ
only Parcel Identification No.(PIN) r
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification
(if well field,one lat/long is sufficient) '
It 1
� Si tun:of ertifi ell ntracOr� Da
6.Is(are)die well(s):1--a rermanent or ❑Temporary
By signing this form,1 hereby certify that the wells)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or copy of this record has been provided to the well owner.
If this is a repair,fill out brown well construction irrfannation and explain the nature of the
repair ruder#21 remarks 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
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple iryection or non-water supply wells ONLY with the some corustrudion you Can
subs&one form SUBMITTAL INSTUC17ONS
9.Total well depth below land surface: a 65 (tit) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if&fferent(ezawle-3 r@r 200'and 2Q100') construction to the following:
10.Static water level below top of casing: 10 (ft) Division of Water Quality;Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Cent I er,Raleigh,NC 27699-1617
11.Borehole diameter: _ (in.) 24b.For Infection Wens: 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 Injectiop Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
Blowing-Rigc. or Water unny&Infection Wells: In addition to sending 13a.Yield(gpm) 30 Method of test: 24 F W S l ding the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chlorine Amount: _OZ. completion of well construction to the county health department of the county
where constructed-
Form @W-1 - North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013