GW1-2022-10627_Well Construction - GW1_20221122

i
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells.
1.Well Contractor Information:
BobbyW. Potts 14.wAmERzoNEs
FROM TO DFSCRWrION
Well Contractor Name o ,' ft O ft l i
NCWC 2028 A ft ft
' IS.OUTERCASING eimul4dsedvidls OR LINER If ble NC Well Contractor Certification Number �
Ferguson's Well and Pump, LLC mom ft TO ft DIAMSIE2� Zr Cut ,�,TI
Company Name 16 G OR-TUBING:tewtherm2l domd4oahl
It 75', , / FROM TO DIAMBTFR THICKNESS MATERIAL
2.Well Construction Permit#: tl Z / ft ft in
List all applicable well construction penrats fl e.Couay,State,Variance,etc.)
ft. ft in -
3.Well Use(check well use): 17 �
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICENESS MATERLAL
OAgricultural ft ft hL
❑ ctpaUPublic
❑Geothermal(Heating/Cooling Supply) I�d'Residential Water Supply(single)� R ft in. '
❑lndustrial/Commercial ❑Residential Water Supply(shared) •18..GROUT-
❑Irrilion
FROM I TO MATEPJAL EMPLACEMZN' 1i=OD AMOUNT
Non-Water Supply Well: ft- 20 ft Concrete Gravity-Flow
❑Monitoring ❑Recovery ft. ft
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediatiou PACK Of mwcablo
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO I MATEPJAL I McLACEMENi'11WMOD
ft tt'
❑Aquifer Test Cl Stormwater Drainageft ft
❑Experimental Technology ❑Subsidence Control s
2�"DRILI,II4GZl1 attacli°adililiiaaalalicebsif
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESLIdMO color,hardnem soMuk etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft ft
� t
4.Date Well ft
s)Completed: /1 �91 Well TD# �n,
52� can
.Wen Location: ft ft.
ft
�,9 t C
K4p HJ Kt i �pr�Ah ft ft
Facility�dwnerdVame FacilitylD#(ifapplicable) ft -
-.
Gig/R L�i�Qny �'�aioyc 22 4"a V21-iff ft ft '�C:U LZI, V" -U
Physical Address,City,and Zip
2L REMARKS.
I��,o</ _1.Z36bga58s4
q-ty Parcel Identification No.(PIN)
iIFTSw3u'dl r7r;;�c:8r�"Urvh
5b.Latitude and Longitude in degrees/minutes/smonds or decimal degrees:
(ifwell field,one lat/long is sufficient) 22.Certification:
N W _ %-" /a/
f
Signature OfCAfird Well Contractor Date
6.Lit(are)the well(s): 21ermanent or "❑Temporary By signag Lhis form I hereby cerdfy tliat the well(s)was(were)constructed m accordance
with 15A NCAC 02C.OI00 or lSANCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing welh OYes or 81Vo copy of this record has been prori&d to the well owner.
If this is a repair,fill out known well consbnction information andesplain the nature ofthe j•
repair under#21 remarks section or on the back of this form. 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 h9ectian or non-water supply wells ONLY with the same consbucium,you can
submit areform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: f/_S (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Fornmhiple wells list all depths tfdfjerett(-wWe-3 00'and 2 100) conshvction to the following:
i
10.Static water level below top of casing: 0 ft,) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" ( 1617 Mail Service Cen�er,Raleigh,NC 276994617
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
11 Well construction method: ry construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground InjectiollControl ftgram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Blowing-Rig 24c.For Water Supply&Tntiecti l WIells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
-13L Disinfection type: Chlorine Amount:S/ OZ. completion of well construction to the county health department of the county
where constructed-
Form CYV-1 North Carolina Department of Environment and Natuml Resources—Division of WaterLi Revised Jan.2013
Pity
- � I