GW1--04152_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:
Bobby W. Potts 14.WATER-ZONES.FROM TO ' , DESCRIPTION
Well CoatractorName ft. ig Qn(U ft
NCWC 2028-A ft ft
•
NC Well Contractor Certification Number , 15.OUTER CASING(far multi-cased wells)OR LINER(If appSable)
FROM TO DIAMETER THICKNESS MATERIAL
Ferguson's Well and Pump, LLC D ft -//4 ft `,75 in. u6,i PeCSD�Z7
Company Name
16.INNER G OR TUBING(acre mat elasedaoopj•_
/� FROM TO DIAMETER. THICKNESS MATERIAL
2.Well Construction Permit#: 202 3 - V 0 S A a, ft. ft in. —
List all applicable well crrrsnuction permits(i.e.County,Stote,Vo dance,etc.)
ft ft in.
3.Well Use(check well use): 17.SCREEN —_
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft ft in.
❑Agricultural ❑❑ pal/Public _
❑Geothermal(Heating/Cooling Supply) (Residential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL ' EMPLACEMENT METHOD&AMOUNT
❑Irrigation Wdl: • 0 ft 20 n- Concrete Gravity-Flow
Non-Water Supply
❑Monitoring °Recovery
ft ft
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACE.Of anntitable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft fi
❑Aquifer Test ❑Stomrwater Drainage
ft. ft
❑Experimental Technology ❑Subsidence Control t
20.DRILLING LOG(attach additional abeels tf necessary)
❑Geuthermal(Closed Loup) ❑Tracer FROM TO DESCRIPTION(cater,eardnesr,soil/roctt type,grate size,etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 69 ft tiro ft (I lay
4.Date Well(s)Completed:��/y/2 y Well QO ft pad ft llpy-d-,405.e
( /10 c Sa.Well Location: /
e*4-LI'� ( -7-r 1 �76 ft. 3v 5 ft (3, ,/ e
en l ta ft. ft
Facility/Owner Name Facility ID#(if applicable) ft. ft. , a„,
.0 q b (t,hU {,Jrii0,2 Lelc..e�ke✓ Q8-71R ft ft
Physical Address,CK and Zips." 21 REMARKS
'.-Ncnr-rY, 6 c 9 l n i t re q?6 ._ y bite
un
Coty Parcel Identification No.(PAT) lax,. x..
Sb.Latitude and Longitude in degreea/minntes/seconds or decimal degrees:
(if well field,one 1st/long is sufcient) 22.Cerfidirstion:
s ° 40 IS e 6i3r-)- N t&),a° M( 'S 'S.l(y l�, w
� Signature o ' ed Well Con for t{-A-1/2'-'1—
6.Is(ate)the Well(a): DPertaancnt or ❑Tenaporaty By signing this form,I hereby certid,that the wel(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or 114 NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or o copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 rnnarkks section or on the back of this form 23.Site diagram or additional well details:
e You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: 6 construction details. You may also attach;additional pages if necessary.
For naultlpi irgectian or nor-water supply wells ONLY with the some construction,you can
submit one fonn I SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 30 S (ft,) 24st. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifctifferent(crumple-3(g200'and 2(100') construction to the following:
10.Static water level below top of using: ;NO ' (&) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Marl Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. ` 6 (in.) 24k For Iniection We11e 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,rotary,cable,direct push,etc.)
Division of Water Quality,Unde:rground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Ma Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 0 6 Method of test: Blowing-Rig 24c For Water Supply&Injection 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 / OZ. completion of well construction to the county health department of the county
1� where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quali.:y Revised Jan.2013 •