GW1--04140_Well Construction - GW1_20240717

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form ear,be used for single or multiple wells •
1.Well Contractor Information:
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14.WATER•ZONFS_
Bobby W. Potts PROM TO . r Dna:a um
Wall Contras:irName ]/(; _ —
NCWC 2028-A ft. ft
NC Well Contractor Certification Number 15.OUTERCASING(fatmultieased'cells)ORLINER(ds liable)
PROM TO DIAMETER THICKNESS MATERIAL
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Ferguson's Well and Pump, LLC `1 y rt S' in. . I '�( t'` /
Company Name 16.INNER CASING ORo)
- PROM [TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: o02 3_ - n Oa 8 9 ft ft. ill.
List all applicable well construction per&L&(Le.Cosoay,Stdbe,Varionce,etc) ft. ft is
3.Well use(check well toe): 17.SCREEN
Water Supply Well: PROM To DIAMETER BLOT SIZE TECIC.KNEES MATERIAL
❑Agricultural ❑ l o ft ft to
❑Geothermal(Heating/Cooling Supply) Water Supply(ciriglr) ft ft is
❑Industtial/Cornmercial ❑Residential Water Supply(shared) 1a GROUT -
GROUT MATERIAL EMPLACEMENT METHOD&AMOUNT
Nn WWaateer Supply Well:On • 0 , c� 20 Concrete Gravity-Flow
ft
❑Monitoring ❑Recovery _ -- ,
Injection Well: ft ft
❑Aquifer Recharge ❑Groumdwater Rctncdiatiou 19.SAND/GRAVEL PACK fir applicaldel
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. f. -
❑AquiferTest ❑StomnwaterDrainage ft. ' R —
❑Experimeatal Technology ❑Subsidence Control . t
20.DRILLING LOG(attach additional sheets if aeersors)
❑Geothermal(CIosed Loop) ❑Tratar FROM TO DFS(RTP'1TON(calor,hardness.sdliroctt nesittam draw ste.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain;miler#21 Remarks) L• it o i, it CI o
4.Date Well(s)Completed. , u L / ffi p/ ft Si' 5 ��
mph . L./� / Well n s ft
lic ,,9(/C
Ss.Well Location: • t ;/. ft s�,[�C
�4 thou 5(,�I�I Vloh 2 C f ft ft (R��� / .
Faciiity/OwncrName Facility ID#(if applicable) ft. ft �,, `.• 4..
1Lk5a 0,i titer Circa_ Q Fle .er o787j tt ft 1 1 Al/4
Physical Address.City,and Zip 2L REMARKS
County Parcel Identification No.(PIN) I U
Sb.Latitude and Longitude in degreeshni nutes/ae:onds or decimal degrees: 22.Certification:wall field,one Wong is sufficient) /
c c� // // t
.ZJ •E,,lv(..X, ✓N 5,1 <6A?.. .STl r W _ 'j/[ : .' / - //_� - ' /---'7'72--'ll---
mre ofCaOca Welt-dmitractof �''-"
6.Is(are)the well(s): eat or OTemporary By signing this fonts 1 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.la this a repair to an existing well ❑Yes or EiNo copy edits record has been provided to the well owner
.fthts is a repar,Jill out berm,well construction irfcen,ation and explain the nature of the
repair under#21 remarks section or on the back of this fonts. 23.Site diagram or additional well details:
You may use the back of this page W provide additional well site details or well
S.Number of wells constructed: construction details. You may also atach additional pages if nerr=inq'.
Far,maltipk bejecNcw or nom-were supply wells Olallwith the sane eawstractiaw,you can
submit one farm. SURMYTTAL INSTUCTIONS
9.Total well depth below land surface: ((!=; (f.) 24a. For All Wells: Submit this form within 30 days of completion of well
Fa mu/tlpk wells list all depths ifdfi rant(example-3@200'and 2(4100) construction to the following:
10.Static water level below top of casing: .1(�' ' (it.) Division of Water Quality,Information Processing Unit,
lfw water level is above casing,use"+" 1617 Mall Service Curter,Raleigh,NC 27699-1617
11.Borehole diameter. C,_ l//Q (m.) 241s.For Insertion Well*: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
U.Well construction method: Rotary construction to the following:
(i.e.anger,rotary,cable,diced push,DM)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Canter,Raleigh,NC 27699-1636
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13a.Yield(gpm) ,? Method of test: Blowing-Rig 24c.For Water Sup&&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chlorine Amount f;•) oz. completion of well construction to the county health department of the county
L where constructed.
Form GW-1 North Carolina Dc aruaent of Environment and Nat ral Resources-Division of Water Quality Revised Jan.2013