GW1-2023-02054_Well Construction - GW1_20230303

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
Bobby W. Potts FROMATE ZONFS DESCRrPT1ON
Well Contractor Name ft 1330
NCWC 2028-A eft . ft
NC Well Contractor Certification Number IS OUTER CASING o:• wells ORIJNER d bk
FROM TO DIAMETER THICEN rec MATERIAL.
Ferguson's Well and Pump, LLC 0 It.
ft in12ttIr 1.2,5
Company Name 16.INNER CASING OR G; dined-I
FROM TO DIAMETER THICKNFSS MATERIAL2.WellConstructionPermit#: ZZ 6n-i Lf�. ft ft ;n
List all applicable well construction permits(Le.Cottony,State,Varance,etc.)
it ft in
3.Well Use(check well use):_ 17.SCREEN
Water Supply Well: FROM TO DLAINE!'FR SLOT SM TLiI MATERIAL
� " �'� ft ft in
❑Agriculhual [�vttr�rpaUPublic
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft m
❑IndustriaUCommercial ❑Residential Water Supply(shared) 18..GROUT _
FROM I TO MATERIAL EMPLACEMENT METHOD a AMOUNT
❑ltr' ation 0 ft. 20 Concrete Gravity-Flow
Non-Water Supply Well: ft ft
[Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACT'fff.andicaMel
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I To MATERIAL I EMPL.AcEmDrr moD
ft ft
❑Aquifer Test ❑Stormwater Drainage fc ft
❑Experimental Technology ❑Subsidence Control
.2a DRILLING LOG attach additional sheets if
❑Gcuthermal(Clused Loup) ❑Traecr FROM TO DFS_1dF'ION color,hardness,solllrock sir etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft .ft v
'ft ft
4.Date Well(s)Completed: e11ID# ft ft
Sa.Well Location ft
.: 7 v C
blat l L/r ft ft
FaciiityfOwnerName Facility IM(if applicable) ft ft Try
Jn r may.^� J ! ­4
/L (2�'�,t,[l9(/Prf�l f'A`c}13 / ft ft :a
'Physical Address,City,and Zip
2L REMARKSN A fl 1 'i
Coun Parcel Identification No.(PIN)
h.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one la1/long is sufficient) 22.Certification:
l tv,D�3t �iS�N ?�3tSO7/ 3A tr W
Signatm of C ed Wel Contractor Da
6.Is(are)the well(s): Ld'Permanent or ❑Temporary By,rim this form 1 hereby cer*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 copy of this record has been provi&d to the well rnmer.
If this is a repair,fill out lawwn well construction o formation and explain the nattre of the
repair render#21 rernaks section or on the back of this fomL 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 agection or non-water supply wells ONLY with the sane constraaYion,you can
submit oneform SUBAIMAL INSTUCTIONS
9.Total well depth below land surface: q19 S A) 24a. For All Wells: Submit this form within 30 days of completion of well
For nwWple wells list all depths if different(exanple-3@200'and 2@1001) construction to the Following:
10.Static water level below top of casing: !f A) 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
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 Injeetio&Control Prggram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-16M
Blowing—Rig24c.For Water Suonly&Iniection Wells: In addition to sending 13a.Yield(grin) Method of test: ding the form to
the address(es) above, also submit one copy of this form within 30 days of
JJ//
.13b.Disinfection type: Chlorine Amount: eyl OZ. completion of well construction to the county health department of the county
where constructed-
Form CAW-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013