GW1-2021-05970_Well Construction - GW1_20211025

W Lt LL LU1V,'1 RU U'HU1V REC:URD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts FROM TONES I DESCRIPTION
Well Contractor Name ft ft
NCWC 2028-A ft ft
NC Well Contactor Certification Number is. CASING ifflawrmd6-eatedwdlsORLINERrf ble
FROM TO DIAMETER Tt3tt•urvtree MATF�pI,
Ferguson's Well and Pump, LLC 0 ft ft is
Company Name 16.-INNER IRNG OR G_ dried
PROM TO DIAMETER T nelmr-3 MATERIAL
2 WellConstruction Permit#: S w -A 1 0 y 3 ft, ft in-
List all applicable well construction pernrits(i.e.County,Btaaie,Variance,etc.)
ft 'ft in.
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMLMM SLOT 9dff—_1 TMCENM I MATERIAL
ft ft in.,
❑Agricultural ❑ pal/Public
❑Geothermal(Heating/Cooling Supply) �al Water Supply(single) ft ft m
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT _
FROM TO MATERIAL EMPLACEMENT METHODS AMOUNT
Non-Water Supply Well: 0 ft 20 n COnrrrete Gravity-Flow
❑Monitoring Recoveryft tt
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK fd.applipplilep
JD
TO MATERIAL EMPLACF f ME!MOD
❑Aquifer Storage and Recovery ❑Salinity Barrier �
❑Aquifer Test ❑Stormwater Drainage
ft
❑Experimental Technology ❑Subsidence Control
NG LUG attuh additinaal meets
❑Geuthermal(Closed Luup) ❑Tracer To DFSC'IUMON color hardness,soturoclt dz etc
❑Geothermal(Heating/CoolingReturn ❑Other(explain under#21 Remarks) ft
ft
4.Date Well(s)Completed: C¢ Well ID# 2 ft5a.Well Lunation: ft
C d r u 1 :)LtC 1 T , &.kCr ft ft
Facility/OWer Name �jFacility ID#(if applicable) ft. ft
13U�e Nor• h Rtwt n br i' e, [5I( t Mir) d87( f ft ft
Physical Address,City,and Zip 21 REMARKS.
�V1C Down 11 hC,39b -7<e728-1 VIA
County Parcel Identification No.(PIN) uU�t
5b.Latitude and Longitude in degrees/ndnutes/seconds or decimal degrees: 22.CerliScation f 3f;O�R SgCi,On
(if well field,one lat/long is sufficient) 4zk /V
.
DW
w
Si cure ofC 'fled W ntrac r ate
6.Is(are)the well(s): ertnancnt or ❑Temporary
It
By stg-g But fonn 1*—&cerhjy that the wells)was(were)constructed in accordance
__� with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Wdl Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or B1Vo copy of this record has been provukd to the well owner.
If this is a repair,fill out brown well construction irrfornation and eWlam the naatrne of dw
repair rouser#21 rernw b section or on the bank of 9=Jcrm 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: construction details. You may also attach additional pages if necessary.
Frn multiple tryection or non-water supply wells ONL r with the sane awns&uction,you can
Submit waefonn. SUBNff1 TAL INSTUCl'IONS
9.Total well depth below land surface IIQC7 (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dgferent(esmnple-3 00'and 2(a31001 construction to the following:
10.Static water level below top of casing: Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" _T°' 1617 Matz Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: - (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Rota above, also submit a copy of this form within 30 mays of corgletion of well
12.Well construction method: ry construction to the follovving: '•�•
(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 27699-1636
Blowing-Rig c. or Water unny&Injecoa Wells: n addition to sen
13a.Yield(gpm) Method of test: g g 24 F Wt S lIti In dmg the form to
the address(es) above, also submit one copy of this form within 30 days of
/
13b.Disinfection type: Chlorine Amount- oz. completion of well construction to the county health department of the county
�E where constructed-
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013