GW1-2022-10595_Well Construction - GW1_20221122

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts axOM� R TO I DESCRR1PI40N
Well Contractor Name ft -2&d
ft
• s
NCWC 2028-A rt /,0 ft
NC Well Contractor Certification Number IS.OUTER CASING orBrdti ed.wg4ft LINER Cif
mom To DIAMETM TMCIagm MATERIAL
Ferguson's Well and Pump, LLC ft 36 ft i" Z C Z
Company Name 16,INNER G OR domed
t FROM TO DIAMETER THICKNESS I MATERIAL
2.Well Constmetion Permit#: 5^] ft ft ;n
List all applicable well construction permits(L e.County,State, wiance,etc.) ft ft irr
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE I THICKNESS I MATERIAL
ft ft in.
❑Agricultural ❑M�ui� blic
❑Geothermal(Heating/Coolmg Supply) esiC�R deatial�Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18'GROUT
FROM TO F MATERIAL EMPLACEM NT METHOD&AMOUNT
❑hri ation 0 ft 20 f Concrete Gravity-Flow
Non-Water Supply Well: ft ft
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK.df e
TO MATERIAL
❑ FROM Aquifer Storage and Recovery ❑Salinity Battier ft ft , EMPLACEMENTWIFIOD
❑Aquifer Test ❑Stormwater Drainage & ft
❑Experimental Technology ❑Subsidence Control e
Z4 DRILLING LOG.attadi additZaoal raheels ff
❑Geuthemal(Closed Luup) ❑Traucr FROM TO DESCREMON color,hardn soiUrock she,etc
❑Geothermal(Heating/Cooling Return ❑Otter(explain under#21 Remarks) D ft (O ft
ft "' S
4.Date Wells)Completed: We11ID tO 2-0# ft ft A5a.Well Location: ft 144 S. ft C
L-ya,les 41-A yc, LP-4l e r ft ft
Facility1dwner-Name Facility ID#(if applicable) fL ft
.Skatjvet R1v Breyar1J ,2A7J ft ft t t
Physical Address,City,and Zips
"ra SulyAniA
Cpunty Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: `Q` x'
(ifwell field,one lat/long is sufficient)
° St �t N s38 `/ /,t(l Yl W
Signature of cd el a for Utz'
,pa6.Is(are)thewell(s): Cwermancnt or ❑Temporary
B3'signing this form,1 hereby tern;fy that the weA(s)was(were)constructed in accordmrce
with 15A NCAC 02C.0100 or 15ANCAC 02C.0200/Pel1 Construction Standards and that a
7.Is this a repair to an existing well: Dyes or o copy of this record has been provukd to the well owner
If this is a repair,fill out brown well construction Wonnation and explain the nature of the
repair wider#21 remmks section or on the back O LW fomx 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 necessay.
For nw1hple agecnan or non-water supply wells ONLY with the sane canstrudiar you can
submit oneform SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: al (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(esanple-3 0'0 artd 2Q100') construction to the following:
10.Static water level below top of casing: 66 00 Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1 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 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 Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Blowing-Rig 24c.For Water SytoDIV&Weed WWells: 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 Amount ko oZ. completion of well construction to the county health department of the county
where oonstructed.
Form CAW-1 North Carolina Department of Environment and Natural Resources-Division of Water Qivality Revised Jan.2013
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