GW1-2022-10573_Well Construction - GW1_20221121

W JNLLL LA N J'1"RU 1 HON RECORD D For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. POttS FROM TO DFSCRUMON
Well Contactor Name r ft v h
NCWC 2028-A ft &
NC Well Contractor Certification Number 15.OUTER CASING flormWA-cosedweUa aRL1NER d Me
FROM TO I DIAMETER I Tmcxr; S MATERIAL
Ferguson's Well and Pump, LLC ft 1 2f1&5 PECSIQ021
Company Nam 16 CASING OR TM G. dosed
t nn // FROM TO DIAMEIFR THICENM MATERIAL
2.Wen Coustraetion Permit#: V U V i t)Ll 7 Q ft ft m
List all applicable well construction permits(ce.County,Stote,'Yarimrce,etc.)
it ft in.
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMEM' j SLOT SIZE THICIt NM MATERIAL
❑Agricultural ❑� Mf�unicipaU t in.Public ft f
❑Geothermal(Heating/Cooling Supply) 13Residential Water Supply(single) t ft ft in
❑Industnal/Commercial ❑Residential Water Supply(shared) '18.GROUT
FROM TO MATE MAL EMPLACFd EIrr METHOD&AMOUNT
❑Irri lion Non-water,S�ipply well: 0 ft' 20 f Concrete Gravity-Flow
ft ft
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/ClkAVEL PACK Cd. e
❑Aquifer Storage and Recovery ❑Salinity gamer FROM TO MATERIAL FMPLACEMENTAlETHOD
ft it' '
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control
2(L DRILLING LOG attach addiitiooal sheets ff o
❑Geothermal(Closed Luup) []Tracer FROM TO DFBCRIPITON color,hardn soll/roctt OW,Valn die,etc
❑Geothermal(Heating/Cooling Return) ❑Cther(explain under#i21 Remarks) d ft I ft
ft ft
4.Date Well(s)Completed: Well ID## ft ft
C
Sa.Well Location: R ft
IAGEa rtSS►�Q �i� ('c 5�-Qw• & ft
Facili j tvnet•Name Facility ID#(if applicable) ft ft
31 y s -
Physical Address,City,and Zip 2L REMARIX
Nendczs6n q(i7d.2glaI Z
County Parcel Identification No.(PIN) k,r^^ � y UNa
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one laUlong is sufficient)
� Signature of fled Well ConiFactor At
6.h(are)the well(s): Of.rmanent or ❑Temporary, By sV-V this form,I hereby certify that the well(s)was(were)casrtncted in accondmrce
with 15A NCAC 02C.0100 or ISANCAC 02C.0200 IEe l Construction Standards and that a
7.Is this a repair to an existing well• ❑Yes or UK. copy of this record has been provi&d to the well owner.
If this is a repair,fill out himm well construction irlfonnation and explain the nature ofthe
repair under#21 remarks section or on the back of this 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 iryectien or non-water supply wells ONLY with the same consbudievn,you can
submit o nefmn SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For mulhple wells list all depths if d ferent(crumple-3@200'and 2Q100') construction to the following:
10.Static water level below top of casing: Yo (g) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Matz Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. - (bL) 24b.For Injection 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 meWod: ry construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injectiog Control Ptpgram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Ralagh,NC 27699-1636
i
13a.Yield(gpm) to Method of test: Blowing-Rig 24c.For Water Suomi&Injection 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 At�unt: � OZ. completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013