GW1--06853_Well Construction - GW1_20241115

WELL.CONSTRUCTION RECORD f T
This form Can be used for single or multiple wells • ?Li
For Use ONLY:
1.Well Contractor Information: LAri# '
I
Bobb W. Potts 14.WATERZONES - .
Y FROM TO a , DESCRIPTION •
Well Contractor Name ft. A. 0 ft. I •
NCWC 2028-A ft ft. I ' •
NC Wall Contractor CertificationNumber iS.OUTER CASING(form cdwdls)OR! (if splicaMc)
Ferguson's Well and Pump, LLC FROM ft TO DIAMPITZR� Tffitvnmuec MATERIAL
• Company Name • • 16.IN ER�1(ORTt> c �r/1�� (JCS p/�Z
} oa 3 - y� FROM TO DIAMETER THICKNESS MATERIAL
IWell Construction Permit#: ft. ft. , to.
List all applicable well construction permits(te.County,State,Variance,etc)
ft ft , in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO . DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑ pal/Pubic ft ft im • .
❑Geothermal(Heating/Cooling Supply) Mkesidential Water Supply(single) ft • ft in •
❑Industrial/Commercial ❑Residential Water Supply(shared) 1&GROUT - .
❑TIrlgatiOII FROM TO MATERIAL ' EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 , . rtft-20 Concrete' _Gravity-Flow►
❑Monitoring ❑Recove• ry ft. ft.
Injection Well: ft ft. 1
❑Aquifer'Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK Of applicable)
FROM• TO MATERIAL _ EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Bather ft. -
❑Aquifer Test ❑StormwaterDrainage '
ft ft
' • ❑Experimental Technology ❑Subsidence Control . ' '' r
20.DR I 1`NG LOG.(atmch additiemd Aunts s ifnecessary)
❑Geothermal(Closed Loup) ❑Tracer FROM To DESCRIPTION(odor,hardness,solltrodt type,grain sbc,etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#2l Remarks) 0 ft. U
?f1 .ft C tCt-y
4.Date Well(s)Completed: a/L/u D#Well I �jt0 ft Ma® ft `�S""'�' a
z) ft /0 ft igc Ga
era.Well Location: ( t�'��" y
(� Jr / t ft / ft
- t 1 di l ] (�Q /f 4(d V YJ ft 2b5 ft
acilky/ rName. Facility I (if applicable)
ft ft
( ' L 1Diiiie a e �/.�./ _ �:.;IT
Physical Address,City,add Zip O r L O
x 21
rau,n(2,mhz g6g67'61Q ( 7
County Parcel Identification No.(P/N) Ir,f5: •' tea:.
J
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: "`
(if well field,one lat/long is sufficient)
22.CertmenIlon:
r
35'3S' 10t.7.3(13„ N ga°cia' 364/003 '" W cure Iff `,, ` ee 2 z c-
Si of Cried Well Conrtac9nr D
6.Is(are)the well(s): 2Pcrmanent or ❑Temporary By signing this form I hereby certify that the well(s)was(were)constructed in accordance
� with 1SANCAC 02C.0100 or 1SANCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or t71Vo copy of this record has been provided to the well owner.
If this is a repair,fill out loiown well construction irrfornurtion tool esplainn the nature of the
repair wider#21 remarks section or on the back of thisfonn 23.Site diagram or additional Well details:
You may r,e the back of this page to provide additional well site details or-well
8.Number of wells constructed: J construction details. You may also attach additional pages if necessary.
For multiple Oyection or non-water supply wells 0 Y with the same construction,you can
submit one form DM1I'1' .I.,)FNSTUCTIONS
9.Total well depth below land surface: 2. S (ft,) 24a. Far All Wells: Submit this form within 30 days of completion of well
For multiply wells list all depths ifd fereat(example-3Q200'and 2Q100') construction to the following: I
10.Static water level below top of casing: • 6-(' (ft) Div-;sion of NV2te:-Quality,Information Processing Unit,
if water level is above casing,use"+" 1617 Mai/Service Center,Raleigh,NC 27699-1617
, I L Borehole diameter. (in.) _4l.i.Dr•In jc=tiou VIelan: In a dditidn to sending the form to the address in 24a
Rota above, also submit a cbpy of this form within 30 days of completion of well
12.Well construction method: ry construction to the following: i' i
(i.e.auger,rotary,cable,direct push,,etc.)
/ Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1 C36 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 30 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 t� OZ. completion of well construction to the county health department of the county
,. where constructed
Form GW-1 North Carolina Department of Environment andNatural Resources-Division of Water Quality Revised Jan.2013 •