GW1-2023-02029_Well Construction - GW1_20230303

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
It TER
Bobby W. Potts FROM TO DESCRIPTION
Will Contractor Name ft ft
NCWC 2028-A ft ft
NC Well Contractor Certification Number I&OUTERCASING foe *ells). . LINER if ble
FROM I TO DIAMETER. TMCIO rcc MATERIAL
Ferguson's Well and Pump, LLC (� ft. f c=c
Company Name 16.INNER CASING OR G.
P n^ FROM TO DIAMETER THICKNESS MATERIAL
L Well Construction Permit#: b O�C b�l� ft ft in
List all applicable well construction pernuis(i.e.County,State,Vorimtce,etc.)
ft ft irL
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural 2e.sidential
ipal/Public [t ft is
❑Geothermal(Heating/Cooling Supply) Water Supply(single) A. ft m
❑Industrial/Commercial ❑Residential Water Supply(shared) 1&.GROUT FROM I TO MATERIAL EMPLACEMENT ALMOD a AMOUNT
❑Irri tion 0 ft 20 fL Concrete Gravity-Flow
Non-water Supply well: ft ft
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRABEL PACK e
❑Aquifer Storage and Recovery ❑Salinity Batti FROM TO MATERIAL Del ACEMENT AEMODer ft
❑Aquifer Test ❑Stormwater Drainage
& ft
❑Experimental Technology QSubsidence Control
.2&DRILLING LOG.(attach additional slims if
❑Geuthtamal(Cluscd Luup) ❑Trauer FROM To DESCId yrrON color,hardn Allroclt stc etc
❑Geothermal(Heating/Cooling Return ❑Other(explain under 421 Remarks) 1 0ft 7 ft
9 ft ft
4.Date Well(s)Completed: Well ID# J,d ft C
Sa.Well Location: I fL ft
�Blel a o j ft ft
Facility/Owner Name Facility ID#(if applicable) K -,
i
IyP An►ighg(!, iihn Dr EaQ4?o `a613 M ft _ --
Physical Address,City,and Zip 21-REMARKS hJ )
�Uncbmh,f ct(.910 3 ta3�4� ,;
County Parcel Identification No.(PIN)
5h.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifwcU field,one laillong is sufficient) 22.Certification.
n.
IS'2 b'%or-y-N 2dS G 71/qr A'y/ w
Si tare MCer
Well for Da
6.Is(are)the weIl rtnan(s): eent or ❑Temporary By slg�g this form,I hereby certify that the well(s7 was(were)constructed in accon*nw
with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or HNo copy of this record has been provlckd to the well owner.
If this is a repair,fill out brown well construction information and esplabr the nature of the
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
J 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 byechon or non-water supply wells ONLY with the same construction,you can
submit preform SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: /�S (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(esmnple-3 00'and 2@100') construction to the following:
10.Static water level below top of casing: �� (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 (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
W Rota above, also submit a copy of this form within 30 days of completion of well
12.well construction method: Rotary construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injecfq%Control Plppgram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
132 Yield(gpm) Method of test: Blowing-Rig RI 24c.For Water Sumnly&Infection 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 Amount OZ. completion of well construction to the'county health department of the county
where constructed.
i
Form CAW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013
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