GW1-2022-10551_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:
Bobby W. Puts FROM4T Two DESCRIPTION
Well Contractor Name & ()ft
NCWC 2028-A h 40 ft
NC Well Contractor Certification Number is.OUTER CMING(for malfi-cmedwells ORUNIMCK ble
FROM TO DIAMETER 1MCKN&SS MATERIAL
Ferguson's Well and Pump, LLC b ft. 0 ft in
Company Name I&INNER CASING OR .G.fatiodkerinal dosed-loon)
^ FROM TO DIAMETER TIECENM MATERIAL
2.Well Construction Permit#: OA�I - �U� S ft. ft in.
List all applicable well cornhuction perndis(i.e.CoeoAy,State,Variance, h ft in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: mom TO DIAMETER SLOT SSM THICHIVFS3 MATERIAL
ft ft in.
❑Agricultural ❑ cipaUPublic
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single)A ft ft m
❑Industrial/Commercial ❑Residential Water Supply(shared) 1&GROUT _
❑hrilion
FROM TO MATERIAL EMPIACENMNf METHOD dt AMOUNT
�
Non-Water Supply Well: ft
20 ft Concrete Gravity-Flow
❑Monitoring ❑Recovery ft ft
Injection well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACTi e
FROM TO I MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier h h• ,
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control
X DRIi.LING LOG:attach additiguil aheetsif r
❑Geuthermal(Cluscd Loup) ❑Tracar FROM TO DFS0UPTION color,hardo sdi oclt lype,Vita dze,eta
❑Geothermal(Heating/Cooling Return) ❑Other( lain under#21 Remarks) 0 ft 'L O .ft 16-
4.Date Well 0 ft $0 It.
Completed: _1 �Well ID# � ft � ft C
Sa.Well Location:
h t ft
�rl�n G` ,c C_6t r V ft ft
Facility/OwnerName Facility ID#(ifapplicable) h ft -+ Q _ tl
p a.�r i
19 ralenti S L in4 1 V " 61 in AR-7 h ft
Physical Address,City,and Zip sj 2L REMARIM
Bun�nmb Of.1 "1 4B(�5/G� „., UrW
County Parcel Identification No.(PIN) ✓ e( - OG
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 Certification
(ifwell field,one lat/long is sufficient) '
, it
3S d3y 6$rd/S1( N °>A /2 y W -
Signature of tied Wetfanti=16i Da
6.Is(are)the well(s): lrmanent or ❑Temporary
BY signing this form,I hereby certify that the weft(s)was(were)conshracted in accordance
With 15A NCAC 02C.0100 or ISANCAC 02C.0200 Will Constrwfim Standards and that a
7.Is this a repair to an existing well: ❑Yes or DNO copy of this record has been proviakd to the'well owner.
If this is a repair,fill out brown well consinnctron irfonmadton and explain the natm of the
repair wider#21 remarks section or on the barb of#=jbrm. 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 wills constructed: construction details. You may also attach additional pages if necessary.
For nmlhple injection or non-water supply wells ONLY�wz the sane udion,yarn can
submit oneform SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 7 5 (D) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(ezarnple-3Q200'and 2 rQr 100� construction to the following:
i,
10.Static water level below top of casing: (ft) Division of Water Quality,Information Pruceasing Unit,
If water level is above casing,use"+" 1617 Matz Service Center,Raleigh,NC 2769-4-1617
11.Borehole diameter. _ (in.) 241b.For Iniection 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 follo)ting:
(i.e.Huger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injectiont Control Pwgram,
FOR WATER SUPPLY nWELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 7 Method of test: Blowing-Rig 24c.For Water Suonly&hriection Wells: In addition to sending the form to
the address(es) above, also submit oic 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 GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013