GW1-2023-02033_Well Construction - GW1_20230303

WELL CUINSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts FROM ATER•TZONES4 DESCRW.nON
Well Contractor Name ft K
NCWC 2028-A ft ft j
NC Well Contractor Certification Number 15.OUTERCASING foemnl4casedytella ORLINER rf Me
FROM TO DLIMrrl 2 r dTCERML 2/
Ferguson's Well and Pump, LLC ft ft , in /1 j
Company Name 16.INNER CASING OR G.1222ftM21 doeed-lou
FROM TO DIAMETER I THICKNESS I MATERIAL
2.Well Construction Permit#: �(Zi�a 65�� ft ft ;n
List all applicable well comiruction permits(I e.County,State,-Variance,etc.) ft ft in
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DLIMITER SLOT SIZE I THICKNESS I MATERLAL
ft ft in
❑Agricultural ❑Munici blic
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
01nigation FROM To MATERIAL EMPLACEMl1S'1'AM110D AMOUNT
Non-Water Supply Well: 0 ft 20 It Concrete Gravity-Flow
❑Monitoring ❑Recovery ft ft
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK Of applicsHO
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft TO ft: MATERIAL EWLACnWiTJ%MMOD,
❑Aquifer Test ❑Stormwater Drainage ft it
❑Experimental Technology ❑Subsidence Control
2a:DRILLING LOG.2thWh additional sheets if
❑Geuthetmal(Closed Loop) ❑Tracer FROM. To DESt.'R MON color,haMa soil/mk gpe,grath size,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) I a ft .ft
1 ft_ . ft
4.Date Well(s)Completed: 1''Well ID# ft ft
d C
•5—a.�W-ell Location:n —fc ft
e ft ft
Facility/Oci�vner Iidamce 1 Facility ID#(if applicable) ft ft '
50 D2�l J[JI tf1��Q C At/ ✓l' (. �S 7� - ft ft MAR 3 2 i
Physical Address,Ciry,and Zip 21.REMARKS
�I An Co o Q-7tJ4N
aunty Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.CertiScation:
(dwell field,one IatAong is sufficient)
Q
3 t)��SR/I 7A/t If
N._f� , ° 33 "5/, Zfl(2 l'W 4VI40 Aa
-
Signature of fled Well Con r DA e
6.Is(are)the well(s): ❑f'Crmanent or ❑Temporary gy signing�form,I hereby certify that the well(s)was(were)constructed in accordance
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 o copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and eWhmr the nature ofthe
repair under#21 n einankr 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
8.Number of wells constructed: construction details. You may also attach additional pages if necessary,
For multiple opection or non-water supply wells OATY with the sameWnsbuchan,you can
subrmt onefo?m SUBMITTAL INSTUCITONS
9.Total well depth below land surface: ;W S (fk) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(exmnple-3Q200'and 2@100') construction to the following:
10.Static water level below top of casing: /0 A) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Marl Service Center,Raleigh,NC 27699-1617
11.Borehole diameter 0-) 24b.For Infection 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: Rotary construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injectioy&Control Pipgram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
Blowing-Rigc.For Water SunDly&Infection Wells: In addition to sending
13a.Yield(gpm) Method of test: 24 �g the.form to
the address(es) above, also submit one copy of this form within 30 days of
-13b.Disinfection type: Chloride Amount: �(/ OZ. completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013