GW1--04159_Well Construction - GW1_20240717

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This farm can be used for single or multiple wells
1.Well Contractor Information: —
BobbyW. Potts 14.WATER-ZONES
. FROM TO ' , DFSCRIIr ION
WW1 Coamct&Name H' , '6 a •
NCWC 2028-A ft. •'".' ft
Z>y(;
NC Well Contractor CatificationNumber 15.OUTER CASING gar andfs.eased wells)OR LINER Of appYeabk]
PROM TO DIAMETER THICKNESS MATERIAL
Ferguson's Well and Pump, LLC 6 ft. 35 ft. &, k> 'm Z 4,(AS .144C5,0�,z r
Company Name 16.INNER CASING OR TUBING(,lei aemal elaaeddoopL ,
FROM TO DIAMETER THICKNESS MATERIAL
2.well Construction Permit#: A 0). 1 - b On `i 3 R - ft in.
Liu all applicable well construction permtls(te.Colony,State,Variance etc) --' —
ft. ft in.
3.Well Use(cheek well use): 17.SCREEN
Water Supply Well: \ FROM TO DIAMETER SLOT SZE THICKNESS MATERIAL
❑Agricultural ❑ „•cipal/pub ft ft in. —
❑Geothermal(Heating/Cooling Supply) n .:deatial Water Supply(einglr) R' ft in. —
❑Industrial/Commercial ❑Residential Water Supply(shared) 18
.GROUT -
❑Itrig8ti0n FROM TO MATERIAL_ F�S..talimnifrisOD&AMOUNT..
p
Non Water Supply Well: ft. 20 ft Concrete Gravity-Flow -,
❑Monitoring ❑Recovery it _ ft --
Injection Well: ft ft
❑Aquifer Recharge ❑Grotmdwater Remediation 19.SAND/GRAVEL PACE f f aspiieslie)
FROM TO MATERIAL TItPLACEIOENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft: —
❑Aquifer Test ❑Stormwater Drainage ft. - R
—
❑Expecitneanal Technology 0 Subsidence Control ' t
20.DRILLING LOG.(attach additional sheets ifnecessary)
❑Geothermal(Closed Loop) ❑Tratxr FROM TO DLSCI2IP'l;tON(calor,hardnesr,sOWrodt type,gram sisa,etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) .::,ft' 249 'It
(�1
R �G' rt4.Datewel(s)Completed: / '/2t(wdllrD# —
3a wen Location: •
p ft' 3 J5 ft e /C
a 3rS ft . .6fr.(LA), �L
7u,*(n nsi )t, ft. it
Facility/Owner Name Facility ID#(if applicable) ft L. L)
ft.--bp,RL1.CCtrthe. 2)_ 1aSIr t)4,L Q_, ,z,7RW)S ft. ft JL 1 'i 2024
Physical Address,City,and Zip XL RFMARTlR _
----r2u„_om bye- q(5 LI VI q oS.gq,moo ram:
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude m degreea/moinutes/se ands or decimal degrees:
(if wall field,one 1allong is sufficient) yy�� �{ 22 Certification:
6 r41 iG- fr N '/r�i' %` d i/i: y'l W %'/; ff. ('(,l 4-'1-1- --
.. ASignature of Certified, rell Contracror '�"[,�`j
6.Is(are)the well(s): QPormanent or ❑Tempora.ry By signing this forma I hereby certify that the well(s)was(were)constructed in avco,do,ce
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 QPTo copy of thus record has been provided to the well owner,
If tots is a repair,fill out brown well construd1 n b osmaton and explain the nature of the
repair under#21 remarks section or on the back Qfihts farms 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 necessary.
For insiltipk iajecdae or non-water supply wells ONLY with the sane carstrathon,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surfacer 3 VS (f,) 24a. For All Wells: Submit this form within 30 days of completion of well
For muhlpk wells list all depths ffdtesm t(example-3@i200'and 2(4100') construction to the following:
10.Static water level below top of casing: 70 ' (ft.) Division of Water Quality,Information Promoting Unit,
Uwater level is above casing,use"+" // 1617 Mall Service Cen ter.,Raleigh,NC 27699-1617
am 11.Borehole dieter: i_ (Q (m.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Rotary above, also submit a copy of this fount within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cablee,direct purl,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Marl Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) _)to Method of test Blowing-Rig 24c.For Water Simply&Inierbata Wells: In addition to sending the form to
a the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chlorine Amount: "?''A oz. completion of well construction to the county health department of the county
where constructed.
Farm GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quaaty Revised Jan.2013