GW1--04177_Well Construction - GW1_20240717

WE'LL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells •
1.Well Contractor Information: —
Potts
WATER•ZOINFS_
Bobby W. Potts FRom T'O - , DESCRU'2 Orr
•Wall Contractor Name ft -7 i< •
i. —
NCWC 2028-A ftit.
NC Well Contractor Certification Number 15.OUTER CASING(O wens)OR LINER Of a�ii m1 e)
PROM TO DIAMETER_I THICIMIS M. CRIAL
Ferguson's Well and Pump, LLC ,, ) .7' n a; /;A le` I Ji I AS R6cp2 z,/
•
Company Name 16.INNER CAMIG OR TUBING(pleotLermal daseddoor2_
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#!: () S S -a U a J 'I 1 3 1 ft ft in.
Li&all gpplicabk well construction panels(.e.County,Staff,Varimace,etc.) - -- -
ft ft in.
3.Well Use(check well use): 17.SCREEN —Water Supply Well FROM TO DIAMETER SLOT 517E THICKNESS _MATERIAL
❑Agricultural ❑MupicipaUPublic ft ft in.
❑Geothemal(Heating/Cooling may) Ci'RResidamtial Water Supply(single) ft ft m. 7-
❑Industrial/Commercial ❑Residential Water SupplyIt GROUT TO(shared) FROM TO MATERIAL —7 nipucammarreoo&AMOUNr
N WWateer Supply Well:on
0 ft 20 ft Concrt:t3 __i Gravity-Flow
❑Monitoring ❑Recovery ft. it --
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACE Of mulct bl
PROM TO MATERIAL EMPLACEMerrru rrRon
❑Aquifer Storage and Recovery 0 salinity Bather ft. ft: - —
❑Aquifer Test ❑Stormwater Drainage ft. — R
—
DExperimeatal Technology ❑Subsidence Control
❑Gautheumtrl(Closed 20.DRILLING LOG(attach additional sheets ifn a�
( Loop) ❑Traua PROM TO Dffilit1PlTON(calor,bardeesa soNeadt tyakarain a2a eta)
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under#21 Remarks) 0 R Gl'i ft calf
()Completed: 6/4 Well UM66 ft: 7(. ft c f[Gr s l d�C
4.Date Well(s) �
sa Wenl inn: . i 7z) ft' 75' ft -z.�ttoe:./C
Dc,wmer►r 14. 1Le 1,1 lefhafn 7r n SaZS ft lxtv/7'tG
•
Facility/0 Name Facility ID#(if applicable)
ft ft.
15SG1 ( t . 0- -4a eoad (t.tCI 14 ft. 1 ft �� • t' r
Ptivsiul Address.City,and Zip XL REMARKS _
l-1.enJcr,s Ci g517 a47 T1 Z024
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: DV.Cs 3 v.i
(if well field,one lattlong is sufficient) 22 Certification:
3 S`/7% /SV N 5 i' ?./3 S.5,/, s ' W ‘e- / ' i C
- Izzi7Zaz_
Signature ofeeertifred Well Contractor
6.la(are)the well(s): BPermaneat or ❑Temporary By,sigh*this fonn 1 hereby unify tin:the well(s)was(were)consirWed to accordance
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 131Qo copy(Phis record has been provided to 4be well owner.
If this is a repair,fill osd/Drown well construction infonnation and explain the nature of the
repair under#21 remarks section or on the back oj this form. 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 multiple infection or non-water supply wells ONLY with the sane eaestruc iar,you can
submit ase fonts SUBMITTAL INSTUCTIONS
9.Total well depth below land sur'facar .c2••S (R.) 24a. For AB Wells: Submit this form within 30 days of completion of well
For multiple wells liu all depths ff de emrf(example-3@200'and 2(44100') construction to the following.
10.Static water level below top of Wig: 7l . (g,) Division of Water Quality,Information Processing Unit,
(f warn level is above casing,use"+" / 1617 Mall Service Ginter,Raleigh,NC 27699-1617
11.Borehole diameter. i` lQ Cm.) 24b.For Injection WeIhe 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.wgor rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ,9 Method of test Blowing-Rig 24e.For Water Sum&&Inieefiaa Wells: In addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection Chlorine Amount �rf OZ. completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013 •