GW1-2021-07783_Well Construction - GW1_20210809

W Lr LL t_%JAb 1 KUl.11U1N KELUKU For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts FROWATER TTONES DESCRIPTION
Well Contractor Name ft31,0ft
NCWC 2028-A R ft
I :
NC Well Contmetor Certification Number 15.OUTER CASING for multi-ctsedweDs ORLWER if ble
FROM TO DIAMETER THICKNESS MATERIAL
Ferguson's Well and Pump, LLC ft R 6 4_ � `
Company Name I&INNER CASING OR G.fewdkermal closed
�7, ,�-7 PROM TO DIA11QEtFR THICKNE4S MATERIAL
2.Well Construction Permit#:----,L7tl� � R R i,r.
List all applicable well construction perndts(I e.Counfy;'State,variance,etc.)
R ft
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft ft in.
❑Agricultural OMuni�c' �blic
❑Geothermal(Heating/Cooling Supply) esiOiC dential Water Supply(single) R ft in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18-GROUT
FROM TO MATERIAL EMPLACENUM METHOD tit AMOUNT
Nonn--Wate
❑ ater Supply Well: 0 ft. 20 R Concrete Gravity-Flow❑Monitoring ❑Recovery ft- ft
Injection Well: R ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK- e
❑Aquifer Storage and Recovery ❑ FROM TO MATERIAL EMPLACDA NT?.WMODSalinity Barrier R R
❑Aquifer Test ❑Stormwater Drainage ft-
ft
❑Experimental Technology ❑Subsidence Control
X DRILLING'LOG.attEh addil owd sheets'
❑Geuthtamal(Clusud Luup) ❑Tracer FROM TO DFSt..RIPnoN color hardo salhoclt etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ittNow
��ft ft
4.Date Weil(s)Completed: Well M# ft- R
5a.Well Location: � R 0 tt W t <
ome S ft ft I j�
Facility/Owner Name Facility ID#(if applicable)
Le&A_h P_r 1,2C1 L MAr_S"i f f ft ft U21
Physical Address,City,and Zip RENL4M 41 ["
• 1AtdlSOv) g758.3a-09��o f ;o�processing
Unit
County Parcel Iiientification No.(PIN) -
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one Wong is sufficient)
S° t �° W
Si f 5ed Well n tar m
6.Is(are)the well(s): ermapeat or ❑Temporary By,sig,fg tics fo?M I]&#cer*that the well(s)was(were)cJ ted in accordmrce
with ISA NCAC 02C.0100 or 15ANCAC 1!02C.0200 Wdl Construction Standen*and that a
7.Is this a repair to an existing well: ❑Yes or C31Vo copy of this record has been pnanabd to the well owner.
If this is a repair,fill out known well construction h fomalion and eViam the nature of the
repair render#21 remarks section or on the back of this form. 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 maniple p9ecam ornm-water supply wells ONLY with the same contra ion,you can
sub"W preform SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: /�S (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(=wnple-3@200'and 2@100') 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 Marl Service Center,Raleigh,NC 27699-1617
11.Borehole diameterAo _-_(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 days of cor�letion of well
12.Well construction method: ry construction to the fulloming:
(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.Yidd m BloWln RI 24 F W c. or Water Supply&Iniection!Wells: In addition to
fgp ) � Method of test: g- g sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13L Disinfection type: Chlorine Amount: Y!t 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 Water Quality Revised Jan.2013