GW1-2021-06766_Well Construction - GW1_20210809

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14:ZOOM
Bobby W. Potts FROM TO I DESCRMON
Well Contractor Name 9 70 ft
NCWC 2028-A M It
NCWe11ConCactorCertificationNumber MOUTERCASING fo1•lat�ti edwe6s ORLMM m
ic
FROM I TO DIAMPTM TMCKNM MATERIAL
Ferguson's Well and Pump, LLC Dft 10 ft1611 SI "` V6112 , C /
Company Name 16 INNER CASING OR TUBING.
` ��� FROM TO D1A1 FR TffiCKNESS MATERIAL
L wen Construction Permit#:. U f< Er ' in,
List all applicable well contruction pernrits(r.e.County,Store,Yarfance,etc.) tt fti
3.Well Use(check well use): 17 SCREEN
Water Supply Well: mom TO DIAMETER SLOT SIZE TIIICKNFSS MATIItIAL
ft ft in
❑Agricultural lie
hL
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft
❑Industnal/Commercial ❑Residential Water Supply(shared) IL GROUT
FROM TO MATEBAI EmPLAczmFNTMETHODisAMOUNT
❑Irri ation 0 ft 20 It Concrete Gravity-Flow
Non-Water Supply Well: ft ft
❑Monitoring ❑Recovery
Injection Well: R ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/(RtAVEL PACK•fif=00cable)
FROM TO MATF1tiAL F2tPLACENUMAWMOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft, ft
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control 2a DRILLffiGLAOM:attadi additraaalAmk
❑Geothermal(Clused Luup) ❑Traecr FROM TO DEltt'R MON color haMn soNrocltVIM d2e,etc
❑Geothermal(Heating/Cooling Return) ❑other(explain under 421 Remarks) ft ,0 &
sd ft
4.Date Well(s)Completed: �Well ID# ft ft
Sa Well Location: ft. 0-5 ft w t e
ft ft
Facility/Owner NawA Facility M4(if applicable) ft ft e's
J f► �lU�l �L)P�� ��GIC. �rLe _ d�� I ft ft
�J
Physical Address,City,and Zip 21 REMARKS
11-�0-�✓� l�ca�(,3� A� �►;
County Parcel Identification No.(PIN) nt;tv�'
•1'�1
5b.Latitude and Longitude in degrees/minutedseconds or decimal degrees: 22.Certification:
(ifwell field,one lWong is sufficient)
r -
3
�' Si of C 'tied Well Co' for
6.Is(are)the well(s): ( 'Permanent or ❑Temporary By strung dos form 1 hereby certify that the weft(s)was(were)cormtracied to accordance
with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Cmmb7 &n Standards and that a
7.Is this a repair to an existing well: ❑Yes or 211(o copy of dos record has been prrniakd to the well owner.
If this is a repair,fill out known well construction blOmmation and eapkdn the native ofdx
repair under#21 remakt section or on the back of d nsform. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple vyection or non-water supply wells ONLY with the sane corrmueftem you can
submit are form SUBMITTAL INSTUCTIONS
9.Total well depth below bud surface: 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if aVerad(eaanple-3@200'and 2@100D construction to the following:
10.Static water level below top of casing: SD A) 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 kn (in.) 24b.For Infection 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 Rotary construction to the folluving:
(i.e.auger,rotary,cable,direct push,etc.)
Division of water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-16M
13a Yield(gpm) _ Method of test: Blowing-Rig 24c.For Water &In'ectimi Welts: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
ape. Chlorine ,� OZ. completion of well construction to the county health department of the county
136 Disinfection Amount: ='mot where constructed
Form OW-1 North Carolina Department of Environment and Natural Resources-D'vision of Water Quality Revised Jan.2013