GW1-2021-02572_Well Construction - GW1_20210809

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES.
Bobby W. Potts mom TO I DFSCRWnON
Well Contractor Name ft
NCWC 2028-A rt `7 "
NC Well Contractor Certification Nvrmber 15.OUTERCASING aedwe�URLEN)iL�
FROM TO I DIAMETER THICENIM MATERIAL
Ferguson's Well and Pump, LLC ft ft in, Z/ C 5 a dLi
Company Nam q 16. G OR TtIHII±TG: closed
Da - ayy !J FROM TO DIAMETER THICKNM MATERIAL
L Wed Construction Permit#: f f tO
List all applicable well const►wrion pertntts ox.CorvAy,State,Variance,etc.) R ft �
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SI.O'rSIZE TffiCENESS MATERIAL
ft & to
❑Agricultural ❑ tpal/Public
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft
❑Industrial/Commercial ❑Residential Water Supply(shared) la.GROUT
FROM TO MATERIAL FAtPLA4M1KHT METHOD&AMOUNT
❑hti ation 0 11 20 ft Concrete Gravity-Flow
Non-Water Supply Well: ft ft
❑Monitoring []Recovery
Injection wen: fc ft
[Aquifer Recharge ❑Groundwater Remediation 10.SAND/GRAVEL PACK.Of
FROM TO MATERIAL ELI�LACEbffiV'r METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier & ft
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control
2BCDRII.LII!1GfA>�.at4chadiiGboidaBeats'
❑Geuthermal(Closed Luup) ❑Tracer FROM I To DEtit.'RIPr1YON rotor earen soruroctt etc
❑Geothermal(Heating)Cooling Return ❑Other(explain under#21 Remarks ft ft - `
it ft
4.Date Well(s)Completed: well ID# C C
5a Well L
__ ocation: ft ft i
M ft
Facility/Owner Name Facility ID#(if applicable) ft ft
IN oIJ Cnnrnri 2 � � ` 3
Physical Address,City,and Zips
— uncr>-nbe. 0(o17418(o 1U7
County Parcel Identi5cation No.(PIN) SOT CJP'rJ
51L Latitude and Longitude in degrees/minutea/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N °,�4.�2(0�7�72 l wJe—
Si of ed Well Contras r
6.Is(are)the we0(s): tdFermanent or ❑Temporary By signtiv LWs form 1"by c-0 that die wells)was(were)cazstrwted in accordance
with 15A NCAC 02C.0100 or 15ANCAC 02C.02001Ye11 Constrwrim Slandavds and that a
7.Is this a repair to an misting wen: ❑Yes or copy a f this record has been prow&d to the well owner.
if this is a repair,fill and Ibimm well conduction b ftmaffon and erpla n the norm of due
repair order#21 ranks section or on do bank of dwfomc 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 wens constructed: construction details. You may also attach additional pages if necessary.
For nndhiple injection or nary-water sgpply wells ONLY with die same eauriuction,you can
submit one form SUBMITTAL INSTUCTIONS
9.Total well depth below land surface• Sf7 s (fit) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dffe?vd(eraanple-3@200 and 2Q100� 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 cast»g,use"+" 1617 Ma Service Center,Raleigh,NC 276994617
11.Borehole diameter. (im) 24b.For Infection 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
12.Well construction method: Rotary ounstnrctiun to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 16M Mail Service Center,Raleigh,NC 27699-16M
13a.Yield(gpm) _ Method of test: Blowing-Rig 24e.For Water Sen mly&In'ecti I Wells:.'In addition to sending the form to
the address(es) abc ve, also submit one copy of this form within 30 days of
13b.1)isinfection
type: Chlorine Amount: -9a 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— 'on of Water Quality Revised Jan.2013
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