GW1-2021-05968_Well Construction - GW1_20211025

WLtaLL l:Vl14b1KU11IUlN K1+LUKU For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
I�LWBobby W. Potts FROM4 TZONFS DFSCRIJMON
Well Coutractor Name R ft
NCWC 2028-A & S ft
NC Well Contractor Certification Number I&OUTER CASING 104ntulti-ca�edwdls ORLINSR d
FROM I TO DIAMETER I THICKNESS nil MATFRDAI.
Ferguson's Well and Pump, LLC ft. z & i" S MKS L
Company Name 16.•INNER CASING ORTURING:toodiernial dosed
© FROM TO DIAMETER THICKNESS I MATERIAL
2.Well Construction Permit#: IX, 17 a U ft. ft-
List all applicable well eoruhvcbon perncts fl.e.Cow*,'State,YariancA etc.)
ft ft in
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO I DIAMEM SLOT SIZE I THICKNESS I MATERIAL
❑Agricultural O blic ft ft �'
❑Geothermal(Heating/Coohng Supply) esiWater Supply(single) ft ft
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUP.
FROM TO MATERIAL DeLACEMENT METHOD a.AMOUNT
01nigation Q
Non-Water Supply Well: ft 20 Concrete Gravity-Flow
ft ft
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACKWasulicaMel
FROM TO MATERIAL EMPLACENIIIV T METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft
❑Aquifer Test ❑Storrawater Drainage g ft
❑Experimental Technology ❑Subsidence Control
20:DRILLING LO :attach additional ate if
❑Geothermal(Closed Luup) ❑Tracer FROM TO DFS(IUMON color hardnesi6 solftclt etc
❑Geothermal(Heating/CoolingReturn ❑Other(explain under#21 Remarks ft 3v tt
fL fL
4.Date Well(s)Completed:Well ID# fc ft
Sa Well Location: 1 R S ft 6l! t-
ft ft
Facility/Owner Name Facility ID#(if applicable) ft ft
100 61,w�uic-tc.) 0AArciu I ,ft ft
Physical Address,City,and Zips
12nAJ\i 50ir, 197a4 ng 47_3 a ;n UVA
County Parcel I&ntiScation No.(PIN) Inform e601,
MKIR
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Ce lion•
(ifwell field,one lat/long is sufficient)
s°ys%S� 75z N Q2°3$'as,/ZG t W 4,V1146,11
_� Srgaanue o "5ed W n tar to
6.Is(are)the well(s): er.;manent or ❑Temporary
By signing this form,I Xreay cerkfy drat the weA(s)was(were)constructed to acrordonce
with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Constriction Standards and that a
7.Is this a repair to an existing well: ❑Yes or o copy of this record has been provided to;dw well owner.
If this is a repair,Jul out known well construction irfonnation and explain the native of&
repair realer#21 remark;section or on the back of thisfm m 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 hyectton or non-water supply wells ONL wish the same udux;you can
subnat oneform SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 36S (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple well;list all depths if different(example-3@200 and 2 cQ100D construction to the following:
10.Static water level below top of casing: � (ft) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Ralegh,NC 276994617
11.Borehole diametea -4-z— - (m.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of elution of well
12.Well construction method: Rotary construction to the following: 1
(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
(gP ) Method of test:13a.Yield m -Blowing-Rig- 24c.For Water Sunok&Iniection Wells: In addition to sending the form to
,�Q
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 OW-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013