GW1--04162_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.WATER-ZONE
Bobby W. Potts PROM TO • a DESCRIPTION
Well Cont act&Name R 2(70 R _ •
NCWC 2028-A it '700 m
NC Well Contractor Certification Number - • IS.OUTER.CASING(for mimed wells)OR LINER(dappBrable)
PROM TO I DIAMETER. L TRICIflNmS )LATE 1AL
Ferguson's Well and Pump, LLC n ==" , , �; '� ./ 2S ��A Sp??.i
Company Name • 16•
• CASING OR TUBING(amidst:mai dosed-hap)
pa - v U S l PROM TO DIAMETER T•ffiCKNESS MATERIAL2.Wen Construction Permit#: ft ft in'
DO all applicable well caradlactton pemdts(ie Cowry,state,Vmim ce,etc.) i< ft ha 3.Well Use(duck well use): 17.SCREEN
Water Supply Well: PROM TO DIAMET51 SLOT EWE THICKNESS MATERIAL
❑Agricultural C --pal/Public b ft ft in.❑Geothermal(Heating/Cooling Supply) dential Water Supply(single) ft ft m
❑lndust ial/Commercial ❑Residential Water Supply(shared) 18.GROUT -
FROM TO MATERIAL __Flew:nu T METHOD&AMOUNT
_
Non-Water amply Well: 0 ft 20 t�
ConcretGravity-Flow
❑Monitoring ❑Recovery ft. ft.
—_,
Injection Well: ft ft
❑Aquifer Recharge ❑Grotmdtvater Remediation 19.SAND/GRAVEL PACK 6f aRI Ib
❑Aquifer Storage and Recovery ❑calinity Barrier PROM TO MATERIAL, EMPLACEMENT
ft. f .
❑Aquifer Test ❑Stotmwater Drainage
f. ft
❑Experimental Technology ❑Subsidence Control r
20.DRILLING LOG Okada>ddtional ieeak lfaee easy)
❑Geuthermal(Closed Loup) ❑Trace• PROM To Dies TTtx�t senor,I n hism_sottime t nyp.,_patn made.)
❑Geothermal(Heating/Cooling Renee) ❑Other(explain under#21 Remarks) 0 fit .3 0 ft ��
R ft
4.Date Well(s)Completed: ;0-C1-Z*el1ID# n3.0 p Q4 1
5s wen Location: • T ) it ? A` kjtli ? � gnC: (4nIIi-ct'�I �'8rfft ft .
FaciZlityy/�Ow/aerName 1 - f Facility IC*(if applicable) 4 _,. . I.
3C1 L 0Oy,(.(_tr (—fin t Ri 4-cJ,P I— a R 1.�a ft. — ft
— ; •_�'1� �%v i
�� `ity,�Zip 2LRut►QAltrra _ t t ?0C�
._ir,[+nrYl be q 6(a y qQ 4Q 8 7 ,n(ew++ -1r4►►4
County Parcel Identification No.(PIN) DiAfCdSGv
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Cert- li
(if wall field,one latllong is sufficient)
3EL'Q\> �7 - , t 54/ S:2. c7) 3 1 .4 ; r Li,2 w 44 'i�,,/�� . 7 a - .7
si ofc Well Contractor
6.Is(are)the well(,): Ef ermanent or ❑Temporary By signing this form I hereby certify that the well(s)was(were)constructed in accordance
�� with I SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Co mid that Standards m that a
7.Is this a repair to an existing well: ❑Yes or LflVo copy of this record has been provided to the well owner.
If this is a repair,fill out brown well construction information and explain the nature of the
repair rider#21 remarks section or an the back of this fonn. 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 riptnils. You may also attach additional pages if necessary.
For multiple tnfectian orraa-water supply wells ONLY with the some construction,you can
submit one font SUBMITTAL INSTUCTIONS
9.Total well depth below land surfaces 1::.L.S (ft,) 24a. For All Wells: Submit this firm within 30 days of completion of well
For nmmltlple wells list all depths if dfisrent(example-3@200'and 24100') construction to the following:
i ••, (ft) Division of Water Quality,Information Processing Unit,
g.
10.Static water level below top of casing: -1;; '
ff hater level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole disinter 0„.. /. GQ (m.) 24b.For Inietion Wells: In addition to sending the form to the address in 24a
Rotary above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: constitution to the following:
(i.e.anger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Car tear,Raleigh,NC 27699-1636
13a.Yield(gpm) ') (.) Method of test Blowing-Rig 24c.For Water Suaply&imiemtion Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
Chlorine c_' completion of well construction to the county health department of the county
13h Disinfection type: Amount: I (• OZ, where constructed
Form OW-I North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Ian.2013