GW1-2021-05895_Well Construction - GW1_20211025

W JLLL UgJlNJ'1 HUU11V1N RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts FROM R TTON DESCRIPITON
Well Contractor Name ft
NCWC 2028-A ft ft
NC Well Contractor Certification Number MOi1TERCASING m�6-casedwrfla ORLINSR rf ble
FROM TO DIAMETER THICKNESS MATERIAL
Ferguson's Well and Pump, LLC ft n Z
Company Name 1 CASING ORTUBING: closed
FROM TO DIAMETER I THICKNESS I MATERIAL
2.Well Construction Permit#: — �014 i - ft ft in,
List all applicable well conowdon perndts fl.e.Cotawy,-'State,Yarimwc etc.)
ft ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM I TO I DIAMETER SLOT SIZE I THINNESS I MATERIAL
❑Agricultural OM micipal/Public ft ft in
❑Geothermal(Heating/Cooling Supply) eResrdential Water Supply(single) ft ft in.
Olndusttial/Commercial OResidential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACIMENTMETHOD&AMOUNT
❑Irn tion 0 ft 20 ft Concrete Gravity-Flow
Non-Water Supply Well: ft ft
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19..SAND/GRAVEL PACK e
❑Agtrifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL T DeLACEMENT I wmoD
ft ft
❑Aquifer Test OStorrnwater Drainage ft ft
OExpetimental Technology ❑Subsidence Control 20:DRILLING LOG:atbdi additional sheets R
❑Geuthermal(Closed Loup) ❑Tra*cr FROM TO DESt]tIPTION cdor hardy sofUrak Olie,ffain d2o,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft ft
2� ft
4.Date Well(s)Completed.*% wen]DOftR29
C
Sa.Well Location: R ft
C
�' htarle5 �asSPr, ft ft
Facility/Ow
_ZLL`ner Name `/ Facility ID#(if applicable) ft ft
�f!ler kod ,5 � �A.)eAa tllllr a�7�7 ft ft
Physical Address,City,and Zip 2L REMARKS
2f e n ef)M k e 917 5/D 9 f,I s��o uV it
County Parcel h3entification No.(PIN) lion pt0
5b.Latitude and Longitude in degreeshninutes/secouds or decimal degrees: 22.Certification: 0
(if well Sold,one lar/long is sufficient)
��� ,i&TLY1 r N gx tiff 7f zyiY " W
Si oYCaAcd Well Contrac r
6.Is(am)the well(s): 914rmanent or ❑Temporstry By sipung dus form;1leiy certify that the weA(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15ANCAC 02C.0200!Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or MC copy of this record has been provided to,the well owner.
if this is a repair,fill out known well consouctron#rforntaaon mud eaplaur the nature of the
repair under#21 re Larks section or on the back of dusfomi. 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-.
Formulliple tryection ornor-water supply wells ONLY with the same constntcam you can
submit acre form SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: yS (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For muMple wells list all depths tf different(--Ve-3@200'mud 2@1007 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,Raleigh,NC 27699-1617
11.Borehole diameter:__ � t(G (in.) 24b.For Iniection WeDa: 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: ry 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 Marl Service Center,Rakigly NC 27699-1636
13a.Yield(gpm) �— Method of test: Blowing-Rig 24c.For Water Supply&Iniectil n'Wella: 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 S 0 OZ. completion of well construction to the county health department of the county
where constructed
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of WaterlQuality Revised Jan.2013