GW1--04142_Well Construction - GW1_20240717

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.V.haTER•ZONES`
Bobby W. Potts FROM TO, , DESCRIPTION
Well Commestoar Name ft jt ) ft •
NCWC 2028-A ft :.5‘, / ft.
NC Well Contractor Certification Number 15.OUTER CASING(for mimed wetl)OR LINER Of appBegio)
FROM TO DIAMETER T MATERIAL
Ferguson's Well and Pump, LLC 0 n ij R (. ,Ate;_'" Z•jii 14', G"(Sj� 2/�
pray Name16.1NNER G OR TUBING(geothermal dased-loop)
6Com p FROM TO DIAMETER THICKNESS MATERIAL
2.Well Coaattneti C Permit#: rt U A - ere i 0 -7 4---ft ft // "r m. j�/'�C-`�!"01(5O'/
List all applicable well oasntvctlon permits(.e.County,Stare,Variance,ell.) `� v (tL�
ft ft is
3.Well Use(check well nse): 17.SCREEN
Water Supply Well: FROM To DIAMETER (SLOTti1ZE THICKNESS MATERIAL
llAgrictalhtral ❑Mtani ' tier ft ft in.
_
❑Geothermal(Heating/Cooling Supply) ❑ ential Water Supply(angle.) ft ft. M.
❑lndustrial/Commercial esidential Water Supply(shared) 18.GROTIT • -
FROM TO MAT RIAT. ' 13,1P.ACEMENTMEIHOD&AMOUNT
❑x tion Simply p ft 20 ft Concrete Gravity-Flow
❑Monitoring ❑Recovery ft ft
Injection Well: fr. ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(If ssudiealAI
ME
❑Aquifer Storage and Recovery CISalinity Barrier FROM TO MATFRlAI_ F�tACtr [rl METHOD
ft. ft
❑Aquifer Test ❑Stormwater Drainage — '
ft ft
❑Experimeaffi1 Technology OSubsidence Control
' t
2d DRILLING LOG(attach adddaaal sheets ifta ry)
❑Geothermal(Closed Loop) ❑Traua FROM TO DESCRIPTIONjcolor,eardeoc,soil/rock time,gram MS,ate)
❑Geothermal(Heating/Cooling Rearm) DOther(explain under#21 Remarks) ' ft >57) ft C (a
y i
4.Date wel(s)Completed: 004well tier#
sa wen Location: • 0 ' ft
e -c'� ''r l`
bg ft-
0,4fl'.nn (firrAsu ft. ft .
Faci(ity/Oweer Name Facility II)#(if applicable) ft. ft i a`,
A �k5 k;1 I e-� Lc,L'res4o- y8 ft ft ��� I +
Physical Address, ',and Zap 21.REMARKS
'11)
1Lr)Ct?m Ln-e q 7 06 r7c 303
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degreea/minntes/seconds or decimal degrees: 22.Certification:
(ifwoll field,one lat/long is sufficient)
t Z.
1 Signature ofOA Well contractor
6.Is(are)the well(s): El etmantnt or ❑Temporary By signfr this form I hereby certify that the well(s)was(were)constricted In acconiasce
with 1.A NCAC 02C.0100 or 15A NCAC 02C'.0200 Well Ccessauctrar Standards and that a
7.Is this a repair to an enlisting well: ❑Yes or Zit copy of this record has been provided to the well owner.
If this is a repair,fill out brow:well construction information and esplain the nature of the
repair radar#21 rtraw*s section or on the back of thus farm 23.Site diagram or additional well details:
/ You may use the back of this page to provide additional well site details or well
&Number of wells constructed: / construction details. You may also attach additional pages if nerPsaars
For mdldple Weed=arnaFwafer supply wells ONLY with the sarwe construction,you can
subunit one form SUBAl2Tr'AL INSTUCTIONS
9.Total well depth below land surfacer { 5 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For tmumpll wells list all depths fat ii(example-3Q'and 2(41100') construction to the following:
10.Static water level below top of casing: () (g,) Division of Water Quality,Information Processing Unit,
.(f water level is above casing use"+" 1617 Mail Service Carter,Raleigh,NC 27699-1617
11.Borehole diameter: V, 62 (m.) 24b.For Injection Wells: in addition to sending the form to the address in 24e
ry above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Rota construction to the following:
(i.e.auger,rotary,cable direct push,etc.) Division of Water Quality,Und ewormd Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) e Method of tee Blowing-Rig 24e.For Water Saintly&Injection Walla: In addition to sending the form to
�yy the address(es) above, also submit one copy of this form within 30 days of
�Disinfectio type: Chlorine Amount: :s� oZ. completion of well construction to the county health department of the county
13where constructed.
Form GW--I North Carolina Department of Environment and Natural Resources—Division of Water Quality Re-viand Jan.2013 •