GW1-2022-06322_Well Construction - GW1_20220705

W L+LL l:U1VN,1KU U,HUN_H li;CORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts 14 WATER
FROM TO I DFSCREMON
Well Contractor Name ft ft
NCWC 2028-A rt (]ft
NC Well Contractor Certification Number 15.OUTER CASING o=ruulti-caSed.1welb ORLINER if me)
FROM TO DIAMETER THICtU'�ttm MATERIAL
Ferguson's Well and Pump, LLC 0 ft- 1 _301, ft. AIC
Company Namc 16.INNER CASING OR TUBING dined ou
i 1 FROM TO DIAMETER. MUCKNFSS MATERIAL
2.Well Construction Permit#: oa10 —6 6 35 -.ft ft in.
List all applicable well construction permits(Le.Cowry;State_Vwiance,ctc.)
ft ft in
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE I TmcKNFSs I MATmi.4L
ft ft in
❑Agricultural ❑ 'cipa]/Public
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) n ft m
❑Industrial/Commercial ❑Residential Water Supply(shared) "'a,GROUT...
FROM TO MATERIAL EMPLACEtvIFtV'r METHOD AMOUNT—
Non-Water Supply Well: 0
❑Im a ft Gravity-
Flow
It Concrete Gi Flow
.
❑Monitoring ❑Recov ft ft
�'y
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACI►, e
❑Aquifer Storage and Recovery ❑Salinity Battler FROM TO MATERIAL EMPLACEMFNTMETHOD
ft ft.
❑Aquifer Test ❑Stomtwater Drainage
K❑Experimental Technology ❑Subsidence Control ft B
TA DRILI IfTGLOG ittlCh additional sheets H
❑Geothermal(Closed Loop) ❑Tracer FROM To DFSCRDYI'ION color hatduess,sollkoclt die,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft ft
ft tt
4.Date Well(s)Completed: Well ID# S t f ) ft
5a.Well Location: ft
U(�� MI w C Inn-alnol,5XV ft ft
Facility%Owner.Namc Facility MN(ifapplicable) ` .
r� ,n �fs�! ft
rt ";-M,9Ea-l .aP_,z
Physical Address,City,and Zip l
2022
21.REMARKS n
aLF .M&
County Parcel Identification No.(PIN) irl �. ^:+;c ;c� ter c:��" ;3 ill
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: _
(ifwell field,one lat/long is sufficient) 22.Certlfieation:
��� S of col W ntrac r Da
6.Is(are)the well(s): ldYermanrnt or ❑Temporary
By signbw thisforn;I herby certify that the well(s)was(were)constructed in accordmrce
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 13 copy of this record has been provi&d to the well owner.
If this is a repair,fill out b umw well construction irrfonnation and eaplain the nature of the
repair under#21 remarks section or on the bark of thfsfonn. 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 multiple irgecam or ton-water supply wells ONLY with the same construction,you can
submit onefom SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 3�Z� M.) 24a. For All Wells: Submit this form within 30 days of completion of well
For muhple wells list all depths if different(example-3@200',vdd 2Qa 100') construction to the following:
10.Static water level below top of casing: 2(/ A) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Marl Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. , _ (in.) 24b.For Tnieetion 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
11 Well construction method: Rotary construction to the following:
(i.e.augcr,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Puogram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield m Blowing-Rig24e.For Water Sunnly&Iniection Wells: In addition to see
(gp ) Method of test: ding the.form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chloride Amount: [ !/ OZ. completion of well construction to the'county health department of the county
where constructed.
Form CAW-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013