GW1--04312_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:
Bobby W. Potts FROM T a , DESCRIPTION
Well Contractor Name ft 00 R
NCWC 2028-A . ft ft
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased.v veils)OR LINER(if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
Ferguson's Well and Pump, LLC D ft 75 ft 6t/25 in- '2//,/> s PliC5j) zf
Company Name 1/� 16.INNER CASING ORTUBING;(geothermal clnsed400p)
OO�S FROM ft. ft
ftDIAMETER in. THICKNESS MATERIAL
L Well Construction Permit#F •
pj 1J0�:
List all applicable well construction permits(i.e.County,State,Variance,etc.). '
ft. ft in
3.Well Use(check well use): 17.SCREEN .
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL _
:Agricultural ❑ ial/Public ft ft in .
OGeothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft in. ,
❑Industrial/Commercial :Residential Water Supply(shared) 18.GROUT. -
FROM TO MATERIAL ' EMPLACEMENTMETHOD&AMOUNT
❑Irrigation 0 ft 20 fr- Concrete Gravity-Flow
Non-Water Supply Well: ft ft `
❑Monitoring ❑Recovery
Injection Well: ft ft.
❑Aquifer Recharge 0 Groundwater Remediation 19..SAND/GRAVEL PACK(if.applicable)
:Aquifer Storage and Recovery . 0 Salinity Barrier FROM TO MATERIAL EMeLAci> xrMErxoD
ft ft:
❑Aquifer Test ❑Stormwater Drainage ft. ft.
:Experimental Technology OSubsidence Control /
20:DRILLING LOG-.(attackaddilmtul sheets if necessary)
❑Geothermal(Closed Luup) ❑Tracer FROM TO DESCIfIP1ION(color,hardness,soil/rock type,grain rate,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) (9 ft v .ft Ca4.Date Wells)Completed: �� 3 Well ID# 60ft. ft �r���C
�� �0 f S ft , -rd//�"OCt�c
aa�/w�Well Location: / 7 5' ft. 3,, S ft /?/�C w�`T G
Poly i rA V\ l�t� t� ft. ft
Facil�itty'//Owner Name Facility ID#/(if applicable) '/
Jg ipWSOY1 1�-fJL'Jr f Sr dP7YS ft ft
ft ft s `+^I'� ..
Physical Address City,and Zip • 2L REMARKS I J I Iq, )
U,N)CGmbe q 70l4393g-5 Jli 4 ' L0Z, •
County ParelIdentification No.(PIN) lfIfi:Cft::rs1,.„1 ,7r-�c. J
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 'f� " i
(if well field,one lot/long is sufficient) 22.Cer4.-,/‘„,
ttfieadtiL:
35 )p( 74/42$' N 6r 2vypf sot (/old8 w 1 ✓%ei - //73
Signature ofCertifi ell Contractor to
6.Is(are)the well(s): PI�J ermanent or El Temporary By signing t ' form,I hereby certify that the well(s)-was(were)constructed in accordance
with 15A 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 Eifilo copy of this record has been praviakd to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the •
repair under#21 remarks section or on the back of this fonn. 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 injection or non-water supply wells ONLY with the sane construction,you can
submit one form - SUBMITTAL INSTUCTIONS '
9.Total well depth below land surface: oc 6 .5 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2 ,100') construction to the following:
10.Static water level below top of casing: _5® (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 :v __ (/i ono 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
IIWell construction method: ry construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injectiopr Control Pupgram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) / Method of test: Blowing-Rig 24c.For Water Supply&Injection Wells: In addition to sending the form to
r
the address(es) above, also submit one copy of this form within 30 days of
13b Disinfection type: Chlorine Amount: rj 0 OZ. completion of well construction to the county health department of the county ,
where constructed.
•
Form C W I • North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013