GW1--04165_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 i4.PROM , DESCRIPTION
Wall Coahaotui Name ft. Ace() ft .
NCWC 2028-A ft. ft
NC Well Contractor Certification Number • 15.OUTER CASING(far amid mod wails)OR LINER Of _I
FROM. TO DIAMETER T MATERIAL
Ferguson's Well and Pump, LLC •
(° (� � f 2%>� 5' ��'c S!�." Z.
Company Name 16.INNER CAWNG OR TO>3ING(thee. emal a oupL_
FROM TO DIAMETERTERCilNFSB MATERIAL
2.Well Construction Permit#: o�b a 3 - 6U5 O5 ft ft In.
List all applicable wen aahstruction permits fie.County,Stye,Variance etc.) ft. ft to.
3.Wail Use(cheek well use): 17.SCREEN —
Water Supply Well: PROM TO DIAMETER SLOT nZE THICKNESS MATERIAL
❑Agricultural ❑ tic ft ft in
❑Geothermal(Heating/Cooling Supply) eater Supply(single) ft ft M. —
❑IndustriallCommercial ❑Residential Water Supply(shared) 18.GROUT � -
FROM TO MATERIAL gliptAcnoovrmireonak AMotwr
[lhrigat 0 ft 20 f• Concrete Gravity-Flow
Non-Water Supply well: • ft. - ft
—� .
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Grotmdwater Remediatiou 19.SAND/GRAVEL PACK Of aepikab 1
FROM TO MATERIAL. inetaCF11t1Qrf MECBOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft
❑Aquifer Test ❑Stoanwater Drainage ft. ft
— — —
❑Fxperime::ttal Technology ❑Subsidence Control '20.DRILLING LOG(attach additional Ants if necessary)
❑Geothermal(CluaexlLoop) ❑Tracer FROM TO D1 1T(�tCedar,hardneardureektype,_g ma�ym )
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under 421 Remarks) 1) 3 J Art el N 1/ /
4.Date Well(s)Completed:" :/A Y Well lD#
' //V ft :I)S' tt: /,i�c i.�/
5a.Wen Location: 'Al
/
AA til 6 m.e.c, LLC � f ft • -� ,1
Faci(ity/OwnerName Facility ID#(if applicable) ft it I.
a 1-1 T s1 I e R-4 Ct LCO t.L4 Cl/ k-rh t.r 73. , ft. ft - • a... V t..,i ,
Physical Address,City,and Zip 21.REMARKS — JL 4 7 94
Cogs-(_ g6,-75s1 7 793
County Panel Idcaticaiion No.(PIN)
—Sb.Latitude and Longitude in degseca/minntes/seconds or decimal degrees:
(dwell field,one IaUlong is sufficient) 22.CertiScatioa:
w '11}4.-e;--G "j/l11/ / /thz1;-' ----L- - ---''''!/-27/-11L--
1)5d4'keif 1321, - 1- -N t9N A11% .30i ./".A Y.'r / 7 At—t7-----''
/ Signature of Certified Well Contractor Hate
6.Is(are)the well(s): QPermanent or ❑Temporary By signing lies form I hereby cerkfy that,he wen(s)was(wen)constructed to accordance
�� with 15A NCAC 02C.0100 or 15A NCAC C2C'.0200 Well Casuructicas Standards and that a
7.Is this a repair to an existing well: ❑Yes or QNo copy of this record has been provided to the well owner.
.jf this is a repair,fill out blown well cozatruction information and erplai n the nature of the
repair under#21 nasals section or on the bath if thisfovm. 23.Site diagram or additional well detnoils:
/ 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 neeecenry.
For multiple by saki,or non-water supply wells ONLY with the same cauatruc8ae,you can
sabnst arse fare. r SUBMT TAL INSTUCTIONS
9.Total well depth below land surface: � (ft) 24a. For Mi Wells: Submit this fain within 30 days of completion of well
For multiple wells list an depths((f4 neiu(example-3(4200'and 2(100) construction to the following:
10.Static water level below top of casing: 3 cr .• (ft.) Division of Water Quality,Information Processing Unit,
If water level is abate casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter (Q (m.) 24b.For Tmleetion Welly In addition to sending the form to the address in 24a
Rotary above, also submit a copy of this farm within 30 days of completion of well
12.Well construcdion method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Pmgram,
FOR WATER SUPPLY;WELLS ONLY: 1636 Mail Service Cancer,Raleigh,NC 27699-1636
13a.Yield(gpm) / / Method of test: Blowing-Rig 24c.For Water Stinouly dti Injection Wells: In addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
13b.Disatltxtion type Chlorine Aunt oz. completion of well construction to the county health department of the county
where constructed.
Farm OW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Ian.2013 •