GW1--04309_Well Construction - GW1_20230626

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells _
1.Well Contractor Information:
Bobby W. Potts •PROM
Aq TO -. , DESCRIPTION -
Well Contractor Name - .. ft. ,Q ft ' I •
NCWC 2028-A n ft
NC Well Contractor CertificationNumber • ' • 15.OUTERCASING�otanitiadwdis)ORIINER(1f )
PROM TO . DIAMETER THICKNESS MATERIAL
Ferguson's Well and Pump, LLC - _ d' 74 ft ‘ti 'n' 2/6r17S' vciP2Z/
Company Name . 16.INNER CASING OR TUSING.(steurberm21 dmedd0UP)
PROM TO _ DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: t9•09t3 — -b6-130 ft . ft - in.
List all applicable well construction permits(i.e.County,State,Variance,etc.). R
3.Well Use(check well use): 17.SCREEN •
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft ft
DAgricultural ❑ Public
ft ft is .
❑Geothermal(Heating/Cooling Supply) afesidential Water Supply(single) -
❑lndusttiaUCommercial ❑Residential Water Supply(shared) •18:.t tt#TIT• - .
FROM To MATERIAL EMPL►CEAMTMETHOD&AMOUNT
❑lnigation 0 ft 20 ft Concrete Gravity-Flow
Non-Water Supply Well: - ft ft.
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19..S;(1ND/GRAVEL'PACK•,tid ie) ..
PROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery _ in Salinity Barrier ft. ft - "
❑Aquifer Test ❑Stormwater Drainage •
ft ft
❑Experimental Technology ❑Subsidence Control ,. t
20:DRILLING LOG(attadi'sdiiii lsheetsifneassar9)
❑Geothermal(Closed Loop) ❑Tracer PROM TO DESCRIPTION(wbr,hardness,sotttrock 67te,Oren she,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) O.ft .[j�+.ft / Y
�
vet 65 ft /'�Sihlil9t
4.Date Well(s)Completed: 444 A3 Well BEM /5 ft 7 A ft dC
5a.Well Location: 7X-ft ' 0 S ft . 6-^a ct e
V-L,A-at f 5 —60 1-n ar ft ft -
Faeilityiuwner Name - - Facility lD#(if applicable) ft r a '� �°4
_ {me'µ r'.'°'.. 'f�-.. ,, xi"`
`. C. tec r Creztc. 'Le l Ce.s rLr .a Er7 q 8_ ft ft & z
Phvsicat Address,City,and Zip . . Nl 21.REMARKS • J l�I V `� �� /
• l .tnco b< • . . RI ea(o as 7i
County Parcel Identification No.(PIN) Itt5 is'-arc.' -..1.4�+.s-,41 ill r i
Lei,°o'Oi 3
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
35 t70►y‘ 1602 " N 91°%/0 7t y l8'Y w 3
Si of ed Well Contractor Da
6.Is(are)the well(s): 211 ermanent or ❑Temporary By strung this form,I hereby certify that the we&(s)"was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISANCAC 02C.0200 Well Construction Standards and that a
• 7.Is this a repair to an existing well: ❑Yes or QNo copy of this record has been provickdto the well owner.
If this is a repair,fill out known well construction afonnafion and explain fire nature of the
repair wider#21 remarks section or on the back of thisfonn. 23.Site diagram or additionalwell 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 imgectwn or non-water supply wells ONLY with the sane construction,you can 5 ��INSTUCTIONS
submit ame form
•
9.Total well depth below land surface: 0-7 (lit,) 242. For All Wells: Submit;this form within 30 days of completion of well
For multiple wells list all depdts ifdifferent(example-3@a 200'and 2@,100') construction to the following:
10.Static water level below top of casing: J Vme .(ft) Division of Water Quality,Information Processing Unit,
If water levels above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter :T.i,. .6 ' (ID-) . 24b.For Injection wilt,+: 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,rotors cable,direct push,etc.) •
Division of Water Quality,Underground Injectiot Control Prpgram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Caster,Raleigh,I TC 27699-1636
13a Yield(gpin) Method of test: Blowing-Rig 24c.For Water Supply&infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
Chlorine oz. completion of well construction to the county health department of the county ,
136 Disinfection type: Atmotmt where constructed. ' i
Form 6W-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013