GW1-2021-05947_Well Construction - GW1_20211025

W L+LL l..VlNb 1 KU l:11U1N K1+UMMI For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
Bobby W. Potts 14.FROM TuONEs DESCRIPTION
Well Contractor Name ft ft
NCWC 2028-A ft zga ft
NC Well Contractor Certification Number 15.OUTER CASING(for mnlfi•cased.wdDs OR LINER if
FROM To I DIAMETER I 7TUC NM I MATERIAL
Ferguson's Well and Pump, LLC 0 & 13 19 & lA'S°- 12 16,,//S I Pt c S /1,�l
Company Name 16.-INNER CASING OR TUBING. dosed-lou
�] PROM TO DIAMEIM I 710CIC4M I MATERIAL
2.Well Construction Permit#:—Q1(,I Vo I I I�j , ft ft in.
List all applicable well coast—fiOn penmts(i.e.COW0,241e,Yarimtce,etc.)
ft ft in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMERBR SLOT SIZE TFHEKN S MATERL4L
❑Agricultural ❑ ipa]/Public ft ft m
❑Geothermal(Heating/Cooling Supply) =tial Water Supply(single) it ft. in
❑Industrial/Commercial ❑Residential Water Supply(shared) 1&GROUT
FROM TO MATERIAL r Del ACEME1rr METHOD a.AMOUNT
❑Iai ate ft 20 ft- Concrete Gravity-Flow
Flow
Non-Water Supply Well:
0 ty_
❑Monitoring ❑Recovery ft ft
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19..SAND/GRAVEL PACKlifspolicaMel
EMPLAC
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. TO- MATERIAL EMENTAIMODft
❑Aquifer Test ❑Stormwater Drainage
ft ft
❑Experimental Technology ❑Subsidence Control 20 DRILI ING LOG:attach additional sheens tt
❑Geothermal(Closet Luup) ❑Tracer FROM TO DFSL1dPn0N color,hardness,sellfroct: d2 etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) t fL
Ili V
ft ft
4.Date Weil(s)Completed: / Well ID# cd ft
30
All A
Sa.W�ell Location: + R ft
ft ft
F
acili
ty
/O
w
ner Name Facility EX(if applicable) Kr
n
l/"I t'nl�ll�If1G ICE CX ��tl�St�t7L1i11F �p /� & ft
Physical Addncss,City,and Zip O�
21.REMARKS
GLe l O-7 0 7 ocessing
County Parcel Identification No.(PIN) ru DwR SgC
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell SeK one lat/long is sufficient)
Signature of 5cd Well Contrac r
6.Is(are)the well(s): ermanent or ❑Temporary
By sigrmig this fosm,1)'iere�y cerYrfy drat the weA(s)was(were)corrs+rrxted in accordance
with IJA NCAC 02C.0100 or 15ANCAC 02C.0200 Wel/Construction Standtodr and that a
7.Is this a repair to an existing well: ❑Yes or copy of this record has been provi&d to the well miner.
If this is a repair,fill out brown well consirwtion irrformation and eaplatn the nature of the
repair under#21 remarks section or on the back of thisforrn 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.
For multiple iryection or non-water supply wells ONLY with the smne eonstrucooP4 you can
submit onefornt SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifd fferent(exmnple-3Q200'and 2@100) construction to the following:
10,Static water level below top of casing: A d (ft,) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Matz Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (in.) 24b.For Inieedon 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
1L Well construction method: Rotary construction to the following: "�•
(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 Sunnly&Iniect.Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13L Disinfection type: Chlorine Amount: (� 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