GW1--06827_Well Construction - GW1_20241115

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells •
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1.Well Contractor Information:
BobbyW. Potts 14.WATER•ZONES_ • . I
. FROM TO • DESCRIPTION
Well Contractor Name ft. 5 6, f
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NCWC 2028-A ft. ft .
NC Well CoatractorCertificationNumber 1S.OUTER.CASING(formulti-casedwdls)OR LINER Oda tie)
PROM . TO DIAMETER ' TAICENESS MATERIAL
Ferguson's Well and Pump, LLC ft. ft* t !/a• in. C
Company Name . 16.INNER CASING OR TUBING( c malddoosed/dosed-loop) ��CJ� `
FROM TO. DIAMETER THICKNESS MATERIAL
7-We➢Construction Permit#: O ()a Lk -co I(D.g ft. . ft. in
List all applicable well construction permits(I e.County,State,'Variance,etc.)
ft It. in.
3.Well Use(check well use): 17.5CREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL -
ft ft in.
❑Agricultural ❑ ipal/Public
❑Geothermal(Heating/Cooling Supply) 2fesidential Water Supply(single) ft. ft in.
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❑Industrial/Commercial ❑Residential Water Supply(shared) is.GROUT
FROM • TO MATERIAL • EMPLACEMENT METHOD&AMOUNT
❑Imgation
Non-Water Supply Well: • 0 , ft 20 , ft' Concrete Gravity-Flow
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediatiou 19.SAND/GRAVEL PACE Of applicable)
PROM TO • MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft '
DAquifer Test ❑Stormwater Drainage •
ft ft .
❑ExpeximeatalTechnology ❑Subsidence Control 20.DRILLING LOG.(attach additional / P
sheets if
❑Geothermal(Closed Loop) . OTracer FROM TO DESCRIPTION(color,hardness,son/rock type,prate she,etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft /l ft ((ay.
4.Date Well(s)Completed: 7141 7 Well ID# 10 dit , .r ft• lO� Sa<2 U / -
ts ft 2O ft. 00116
of Well Location: T
L�r1 Mt' L�iri[ 13�) ft 7(S ft 64,0 ""Ce
t1C
ft ft .,
Facility/ownetNamc FacilityIlh"(if applicable) e L . 'M.� h__-
ft ft
l! 1 � LV CT
7'`i d e h tfif ibar Lvia� Plc,{��o v a g73 3- ft - ft. NO
Physical Address,City,and Zip 21.REMARKS I r.' 7_s. ; :,,. ^c-::..,-,U.
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certifiication. 1
Signature of�Y~Well Contrac r OILY-
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6.Is(are)the well(s): QPermanent or ❑Temporary By signing this form,I hereby eel*.that the well(s)was(were)constructed in accordance
with ISA 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 El(C copy of this record has been provickd to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the S
repair under 021 remarks section or on the back of thisfomm. 23.Site diagram or additional well details:
S;Number of wells constructed: IYou may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
For multiple ispection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 7os (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
. For multiple wells list all depths(fr&fferent(example-3Q200'and2Q100') ' construction to the following:
10.Static water level below top of casing: 0 (ft,) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: .i` 6 (in.)' 24b.For Tniection Wells: 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,Underground Injections Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) • Method of test: Blowing-Rig 24c For Water Supply&Infection 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: O OZ. completion of well construction to the county health department of the county
where constructed.
FormCW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013 •