GW1-2022-10566_Well Construction - GW1_20221121

WELL CUN51'RUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Polts F4.WATM 'TONES DESQtII770N
Well Contractor Name ft ft
NCWC 2028-A ft ft f
r 15-OUTER CASIlVG or multi-cma wells OR LINER d bk
NC Well Contractor Certification Number ,
FROM TO DIAMETER THICKNESS MATERIAL
Ferguson's Well and Pump, LLC ft � in. A C SJMZL
Company Name 16.INNER CASING OR TUBING.
t FROM TO I DIAMI TFR I T1HCKNE44 I MATERIAL
2.Well Construction Permit#:-im c AA — e� 3 ft ft in
List all applicable well construction perncts(Le.County,State,41artance,etc.)
ft ft in
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER SLOT=E--1 THicKNFS3 I MATERIAL
❑Agricultural ❑ blic ft ft in
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(singie)h it ft in
❑Industrial/Commercial ❑Residential Water Supply(shared) 11L GROAT
FROM I TO MATERIAL EMPLACEMENT METHOD dt AMOUNT
❑lrri ation
Non-Water Supply Well: ft 20 Concrete Gravity-Flow
ft ft
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19 SAND/ VEL PACK e
❑Aquifer Storage and Recovery D Salinity Barrier . FROM I TO I MATERIAL EMPLACEMENT11tEMOD
R � ,
❑Aquifer Test ❑Stormwater Drainage ft ft ,
❑Experimental Technology ❑Subsidence Control 20:DRILLING LOG.sonar"additional Ameft U
OGruthtamal(Clused Luup) ❑Tracer FROM I TO DL%Id'IYON color,hardnew,soiUroclt qjm,grain d2e.etc
❑Geothermal(Heating/Cooling Return) ❑Other( lain under 421 Remarks) ft 2,97ft (
ft ft
4.Date Well(s)Completed: Well ED# ft ft.
5//a11.Well Location: t ft S ft
l kOt 10.5.1 Al AnLW 'gf A 09 u ft ft
Facilityl cvacr Name 1iFacility ID#(if applicable) ft ft
15 Dnue l o aw P tsn.f 0 9 7l(o ft ft _'. -
Phv�sical Address,City,an 'p G �
�I_,ANtIAJOn 6G78 -y1e -a 331
County Parcel Identification No.(PIN) lnivilTtC1 Ct`.<
I
Sh.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,ire latAong is sufficient)
r? U
N $RV WOd 7 �i2 �r W
Si of crux ed W ntrac r 4
6.Is(are)thewell(s): CHFermanent or ❑Temporary
By signing this Torn~1 hereby cerfijy that due well(s)was(were)caaslrucred in accariarce
with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 We11 Construction Standards and that a
7.Is this a repair to an existing well: Oyes or o copy of duns record has been prow"to d w well owner.
If Ats is a repair,f/out known well conso7wdon Wonnation and esplarn the nahve ofthe
repair under#21 ranarb section or on the back of dus fomc 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 multiple hyecdon or non-water supply wells 01QY with due same covtstradian you can
submuaneform SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 72_57 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depAs rf dr erent(ermnple-3 00'and 2 aJ00') construction to the following:
10.Static water level below top of casing: IYO (ft) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter., to (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Rota above, also submit a copy of thus form within 30 days of completion of well
12.Well construction method: ry wnstruction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injectio&Control Prpgram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-16M
(gp ) � Blowing-Rigc. or Water Supply&Injection Wells: In addition to sending form to
13a.YiYieldm Method of test: 24 F W �the
the address(es) above, also submii 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 CAW-1 North Carolina Department of Euvimnment and Natural Resources—Division of Water Quality Revised Jan.2013