GW1--04292_Well Construction - GW1_20230626

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Nell Contractor Information:1�
Bobby W. Potts 14.FROM •WATER-ZONES;
•.. DESCRIPTION
Well Contractor Name • ft. /zio ft
NCWC 2028-A ft 2.70 ft 1 1 •
NC Well Contractor Certification Number 1S.OUTER CASING(for multi-eased wells)OR LINER 6f applicable)
FROM TO DIAMETER THICKNESS MATERIAL
Ferguson's Well and Pump, LLC aft ycl f. (45 i.,. 1 l$ .57�CC /
Company Name 16.INNER CASING OR TUBING(aeuthermal dosed-loop)
r' / FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: a A•1 U O 1( off 7 g8 . ft ft. in.
Dst all applicable well construction permits(Le.County,State,Variance,Mc.) .
ft ft in. .
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑ crpal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) [Residential Water Supply(single) ft it in
❑Industrial/Commercial ❑Residential Water Supply(shared) is..GROUT. :. - .
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20 R- Concrete Gravity-Flow
Non-Water Supply Well: ,
ft ft.
OMonitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge 0 Groundwater Remediation 19..SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery . ❑Salinity Bather ft. ft: - •
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology OSubsidence Control f
2I DRILLING LOG(attach additional sheds ff necessary)
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness,son/rock type,grata sire,etc.)
OGeothermal(Heating/Coolin`glReeturn) ❑Other(explain under#21 Remarks) 0 ft ZO .it C tar
�y� .
4.Date Well(s)Completed: 7(/,/,2) Well ID# s ft �a 11 S/p c
5a.Well Location: it tI q C ft 'it
( J /
1 C/Y11a I1 t-tn I IPCr 't" ft. ft 1 ' t
Facility/Owner Name Facility ITN(if applicable) s V t` �
e .,e �ri
ft. ft
(,Web Pk B rlt- ( vroVt.CI {-(tn�irsgtnatlu a1•BTea. ft • ft" JVti "3 �u6'-
Physical Address,City,and Zip •
2LREMARKS ...,,F.v.e.,'A VlY'w
�t-Y1rArr.SnY1 a sa BN 4 a t98 ►n•�=r��ti:���A' '��.�
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
3Sr_35`t/S, 7/y.�,l/N 5At) 0O 1`(1 '/YI/ t I w 4d6 1/jgA
Signature of 'fled Well Con for 502/2,__
6.Is(are)the well(s): P� Crmanent or ❑Temporary
By signing this form,I hereby certify that the well(s)`was(were)constructed in accordance
with ISA NCAC 02C.0100 or 15A NCAC 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 explain the nature of the •
repair wider#21 romans section or on the back of thnisfomr. 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 irgectian or non-water supply wells ONLY with the same construction,you can
submit one form SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 3-/S (tit,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'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 casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: :`._ 6 (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 method: ry construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) "\D Method of test: Blowing-Rig 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit'one copy of this form within 30 days of
136 Disinfection type: Chlorine Amount: ) oz. completion of well construction to the county health department of the county ,
where constructed.
Form C-V/-I - North Carolina Department of Environment and Natural Resources-Division of Water Qtiality Revised Jan.2013 .
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