GW1-2021-02501_Well Construction - GW1_20210809

WZLL L;VNb'I'KU1;'11VN RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Inn&rmadon:
WATER ZO
Bobby W. Potts mom TTONFS DESCR>pil'ION
Wen Contractor Name & V
NCWC 2028-A ft a ft
NC Well Contractor Ccrtification Number I&OUTER CASING Nor malficteedwellsORIINERd
FROM TO DIAMETER TIiICKNFSS MATERIAL
Ferguson's Well and Pump, LLC (1) ft- oRS'- Z/ Z
Company Name 16.•INNER CASING OR TUNNG'igeodiermAl erased
PROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: � ft ft in
List all applicable well construction pemrits(i.e.Cortrrty,'State,Variance,etc.)
R ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLAT SIZE THICKNESS MATERL4L
❑Agricultural ❑ ipal/Public ft ft in
❑Geothermal(Hcating/Coohng Supply) esidential Water Supply(single) ft ft. in
❑lndustrial/Commercial ❑Residential Water Supply(shared) lit GROUT
FROM TO MATERIAL FMF1 ACEIYffiV'1?4M0D!AMOUNT
0 it 20 fL Concrete Gravity-Flow
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. ft
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVIL PA 11f.applicoNel
FROM TO MATERIALI EMPLACEMENTAOPTHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier & ft
❑Aquifer Test ❑Stomrwater Drainage R ft
OExperimental Technology ❑Subsidence Control 2a DRILLING Lt LOG—attach additional shs if
❑Geothermal(Closetl Luup) ❑Trauer FROM To DFSCRiPrION cuter,hardo sdurocn typr,own m etc
❑Geothermal(1leatin ooling Return) ❑Other(explain under#21 Remarks) I ft. 0 ft All
ft It.
4.Date Well(s)Completed: Well ID# it
d
Sa.Well Location: ft ft
ft�.S S ft t C L/,rr�-S-�ll"
Facility/Owner Name Facility ID#(if applicable)
J JY I)q[cVa le p��e4 tlen�[c k ��l ftft ft
Physical Address,City,and Zip 21 REMARKS
c Sun .No q
County PareellaentificationNo.(PIN) �Mro�c+4Si 1'.
Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well ficid,one Wong is sufficient) 22.Certification:
3 Lt AjfM/ N _ LW/SS, /7 _w
Si fled Well Con to re
6.Is(are)the well(s): OPermancat or 2'I'e1porary
BY stgrcr:g this form,I &&cerk;fy that the weA(s)was(were)constructed in accordmrce
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: Dyes or o copy of this record has been proviakd to the well owner.
IfOus is a repair,fill out brown well construction hjromwtion and mphmt the nature ofdw
repair under#21 rmuu*s 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
construction details. You may also attach additional pages if necessar}S.Number of wells constructed: I
For multiple apection or non-water supply wells ONLY with the saute eonsfrucrion you can
submit ore form SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: Lf10S (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depda if dfferad(exmaple-3@200'mid 2@100� construction to the following:
10.Static water level below top of casing: 736 (ft.) Division of W ater Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Marl Service Center,Raleigh,NC 276994617
f
11.Borehole diameterko (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 bays of setion of well
12.Well construction:method: Rotary construction to the fulloaing:
(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,RaleW NC 27699-16M
13a.Yield(gpm) Method of test: Blowing-Rig 24c.For Water Stmnly&Iniectitin 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: S(� OZ. completion of vtell 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