GW1--04135_Well Construction - GW1_20240717

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can he used for single or multiple wells
1.Well Contractor Information:
BobbyW. Potts 14.WATER-ZONES_
FROM TO , DESCRIPTION
Wall Contraator Name ft 1f( ft
NCWC 2028-A ft ft
NC Well Contactor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(d app6able)
FROM TO DIAMETER THICKNESS MATERIAL•
_
Ferguson's Well and Pump, LLC ; ft )
'( ; ft (2(A " 2.JG / A Py(S10/1L%
Company Name 16.INNER CASING OR TUBING(maithcrmal dwd-loop_
•
a p
Q FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: aDD.1 ` (j�� ft ft in.
List all applicable well construction pernits(Le.Camay,State,Variance etc.) -
ft ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER MOT=LE THICKNESS MATERIAL
ft ft in.
❑Agricultural ❑ ipal/Public _
❑Geothermal(Heating/Cooling Supply) esidenh ft ft in.
al Water Supply(single) —
❑IndustriaUCommercial ❑Residential Water Supply(shared) 18.GROUT _ -
FROM TO MATERIAL . E PtACEMK TMETHOD&AMOUNT
❑Irrigation 0 ft 20 ft Concrete Gravity-Flow
Non-Water Supply Well: - —
❑Monitoring ❑Recovery ft _ ft
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediatiou 19.SAND/GRAVEL PACK Of appi cabe)
FROM TO MATERIAL EMPI.ACF.MENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft - -
❑Aquifer Test ❑Stomawater Drainage ft
❑Exprsimental Technology ❑Subsidence Control / P
20.DRILLING LOG.(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DFSCSUPTTON(color,hardness,eelthock type,grain doe,etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) f 2 ft. /�
4.Date Wells)Completed: / Y Weu ID# !t 0 ft Y 7X to � s
I 77:- 530 rt /1st 4irlC
3a Well Location: •
g 7(�o ft- %// S ft /' � t
C!1- L Cot ra l-ir j,LLC ft. ft U- .
Facility/Owner Name J Facility ID#(if applicable) _
ft ft ;—....,0
111 Pro')A tac i t e 1-t'^r) UV Lk. c�4l ul i(.t l ,Q P113r, ft ft t N• •.'•L. ,/ 1
Physical Address,city,and lip 2L REMARKS U L 1 .I Z Q Z 4
,unromL,k, a(lett0lIra az6a _
County Parcel Identification No.(PIN) vv.,•-.it t
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if wall Sold,one lat/long is sufficient) 22.Certification: a.j ;?6- -
3SaV 1///51`/t t N )` 3 /(, (�3 7-z w i S A 5/Si ofCertid Well Cor
6.Is(arc)the well(s): l rmanent or ❑Temporary
B3'signing this form I hereby certify that the well(s)was(were)constructed to accordance
�'
� with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Ls this a repair to an existing well: ❑Yes or RN° copy of this record has been provided to the well owner
!f this is a repair,fill out known well construction information and explain the nature of the
repair under#21 raewlce section or on the back of thisform. 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 byection or non-water supply wells ONLY with the sane construction,you can
submit are forma SUBMTITAL INSTUCTIONS
Li i,
9.Total well depth below land surface: /f (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if rGfferenr(example-3(4200'and 2(100') construction to the following:
10.Static water level below top of casing: L(4i ' ( ) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
1L 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 foam within 30 days of completion of well
ILWell 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) c>.' Method of test: Blowing-Rig 24c.For Water Simply&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: t-�i Y• oz. completion of well construction to the county health department of the county
where constructed_
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013 •