GW1-2023-02052_Well Construction - GW1_20230303

WELL LUINSTRU CTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts 14.WATT?1t-
FROM TO ESCRTnON
WcllConttactorNamc ft ft
NCWC 2028-A ft ft
NC Well Contractor Certification Number lS:OiTfER ING foearulti.e*wd.wdls OR LINER fif Ike
FROM TO Dtai,.raTER THlrrrwuec MA�AL
Ferguson's Well and Pump, LLC ft I ft -' in 2_1 A C
Company Name 16.INNER CASING OR G; dased-lau
^ FROM TO DIAMETER THICKNESS MATERIAL
2 Well Construction Permit#:- t ft
List all applicable well construction permits(i.e.County,State,Varrance,etc.).
ft ft in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE I THICKNESS I MATERIAL
❑Agricultural 7e.sidntial
pal/Public ft ft is
y/
❑Geothermal(Heating/Cooling Supply) Water Supply(single) ft ft in
❑Industrial/Commercial ❑Residential Water Supply(shared) 1&GROUT _
FROM TO MATERIAL EMPLACEMENT METHOD et AMOUNT
❑Irri ation ft 20 It Concrete Gravity-Flow
Non-Water Supply Well:
ft ft
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediatiou 19.SAND/GRAVEL PACK ff amikaMe)
❑Aquifer Storage and Recovery ❑ FROM TO MATERIAL EMPLACENUM A=01)Salinity Barrier ft ft: -
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control P
20:'DREUJ NG LOG:atta&additional sbeeb if
❑Geuthtamal(Closed Loup) ❑Traces• FROM TO DESCRIPTION color,Garda soll/mIL qp,,grain size,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft ft 1
ft ft
4.Date Well(s)Completed: Well ID# D ft ft C
Sa.Well Location: tl ft ® ft ' - f
�V eAle-
t. ft fl.
Facility%Owner Name Facility ID#(if applicable) 'r
ft ft
j yo', l.'I y,P 5rt rr n n A n'va z 0&7 ft ft
Physical Address,C' ,and Zip MAR I' n •� '
21.REMARKS � .
un t^b hn 1 cl(a8 8131 913
County Parcel ldcnti5cationNo.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient) `^f �� /�
� trN 92 V 21�tCLYt�R'
Suture7ced Well a.trat r a
6.Is(are)the well(s): errnaucnt or ❑Temporary
, sigrcrrg . r,I hereby certify that the well(s)'Ivas(were)conshwcted in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 lVell Const=fion 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 erplabr the nature of the
repair under#21 remarks section or on the back of this form 23.She 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 uyecuon or non-water supply wells ONLY with the same construction,you can
submit one form SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dffermt(exmnple- @@200'and 2@100') construction to the following:
10.Static water level below top of casing: �D (ft,) Division of Water Quality,Information Processing Unit,
If water level is above casbrg,we"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: _(in.) 24b.For Injection 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 cable,
method. Rotary construction to the fallowing:
(i.e.auger,rotary,cablee,,direct push,etc.)
Division of Water Quality,Underground InjectiolkControl Rmgram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-16M
(gp )_� BIOWIn RI c.For Water Sumnly&Injection Wells: In addition to sending 13a.Yield m Method of test: Blowing-Rig 24 ding the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chlorine Amount C� OZ. completion of well construction to the county health department of the county
where constructed
Form G W-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013