GW1-2022-06314_Well Construction - GW1_20220705

WELL UOINS'IRU(TION-RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobb W. Potts 14.WATER
Y FROM TO DF_SCRIIMON
Well Contractor Name ft 170 ft
NCWC 2028-A ft /) it
NC Well ContiactorCcrtificationNumber 15.OUTERCASING forti ed.eells OR LINER if
Ferguson's Well and Pump, LLC EOM ft TO D eIAAWTIM 7MCEnM AUTEWAL
(�] i 5-
C Z
Company Name 16.INNER CASING OR-TURING fma&wnmi amaa-lair
�t �] 1 FROM TO DIAWMAX. TINCKNESS MATERIAL
2.Well Construction Permit 0.. OJ �'�(� ,ft. ft in
List all applicable well construction petrttits(l.e.Cowny,StxA,'Varumce,etc.)
ft ft in.
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMI,TTER SLOT SIZE THICKNESS I MATERL4L
ft ft is
❑Agricultural ❑M cipal/Public
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT.
❑Teri ation
FROM TO MATERIAL Del ACEMENTMETHOD�AMOUNT
Non-Water Supply Well:
0 ft 20 f Gravity-
Flow
Gi Flow
❑Monitoring ❑Recovery ft ft
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL'PACffif mudicsibla
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EWLACMM3 VT?4MrHODft fi: a
❑Aquifer Test ❑StormwaterDrainage fL ft
❑Experimental Technology ❑Subsidence Control /
.20.DRILLING LOG.attaefi adi i i nand sheets if
❑Geuthermal(ClusedLuup) ❑Trauer FROM TO DFSLIdMON color,hardness,WUre& 92e,etc
❑Geothermal(Heating/Cooling Retain) ❑Other( lain under#21 Remarks) 0 ft ft
4.Date Wells)Completed: Well ID# S ft. 5 S ft
& vo ft c
5a ell Location: it y S tt 611 A.W tC
ft ft
Facility'/ -Name Facility ID#(if applicable) ft ft
J ft ft
Physic ass,City,an�d,/Zip D /A 21.REMARKS. t.
County Parcel Identification No.(PIN) Ini�,eh""r lrr't:^z�J
5b.Latitude and Longitude in degrees/ndnutes/seconds,or decimal degrees: 22•Certification:
(if well field,one lattlong is sufficient)
W
r o fied Well Co tar Vic6.Is(arc)the well(s): errnanent or ❑Temporary By signing this form I hereby certify that the well(s)was(were')constructed in accordance
with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Consshuiclim Stondmds and that a
7.Is this a repair to an ezistmg well: ❑Yes or lr1Vo copy ofthis recordhas been provi&d to the well owner.
If this is a repair,fill out(mown well construction b onnation and esplam the nature ofthe
repair under#21 ranarks 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
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple irgearon or nor-water supply wells ONLY with the same constracLfott,you can
subtmt one form SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: > (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For nwhiple wells list all depths if different(exmnple-3@200'annd 2@100 construction to the following:
10.Static water level below top of casing: [/ A) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Mad Service Center,Raleigh,NC 27699-1617
11.Borehole diameter (in-) 24b.For Iniection 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: ry construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Pengram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield m Blowing-Rig2c. or Water Srmnly&Injection Wells: In addition to sending(gp ) ��_ Method of test: 4 F W ding the.form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chlorine Amount: SQ OZ• completion of well construction to the county health department of the county
�! I where constructed-
Form fiW-1 - North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013