GW1-2022-06325_Well Construction - GW1_20220705

WL•LL UU1VNIXUC;'MN'lu+'CORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts FROM�TER.TO DESCRIPlLON
Well Contractor Name ft ft
NCWC 2028-A a ft ft
NC Well Contractor Certification Number IS.OUTERCASING forriaulti�eafedvtiDa OR LINER if ble
FROM - TO DIAMETER' �CKNM MATERIAL,
Ferguson's Well and Pump, LLC ft ft f
Company Name 16.INNER CASING ORTUBIlVG dmed4 '
�j FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit Myr �/ 'U�.cJ •7 ft ft in
List all applicable well cansttuctton pemels ri.e.CosmV,State,Variance,ek.)
ft R in
3.Well Use(check well use): 17 SCREEN
Water Supply Wefl: FROM TO DIAMETER I SLOT SIZE MCKNESS MATERUL
ft ft im
❑Agriculttual ❑ cipal/Public
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) M ft in
❑Industria/Commercial ❑Residential Water Supply(shared) L.GROUT... _
MATERIAL EMPLACEME AMHOD 8-AMOUNT
❑on- aaon FROM TO MATER ft. 20 Concrete Gravity-Flow
0
Na-Water Supply Well:❑Monitoring ❑Recovery ft. ft
Injection Well: ft M
❑Aquifer Recharge ❑Groundwater Remediation 19 SANDIGRAVZL PACK Of. e
FROM TO MATERIAL fi EMPLACEMFNIIIIIRTLOD
❑Aquifer Storage and Recovery ❑Salinity Barrier &
❑Aquifer Test ❑Stormwater Drainage
ft ft
❑Experimental Technology ❑Subsidence Control
T.l�DRII.LII4GLOG aWeS sdditinoal nheets if
❑Geuthermal(Closed Loop) ❑Tracer FROM I TO DESt.TaMON color b&Mnft&sotUmk sbe,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) D ft S D .ft 1
tt 7 ft
4.Date Wells)Completed: Well ID# ft
- Well Location: 76 ft F�YYO ft 1
``//�� e
✓f� 5 -t-I R ft
_fFacilitylO�wa/er�3dame Facility ID#(if applicable) � •'- .^ "
6-e
fL ft
29 Gd J ft ft
Physical A City,and Zip
21.REMARKS.
County Parcel den eation No.(PIN) !t
"pav(�.
5b.Latitude and Longitude in,degrees/minutes/seconds or decimal degrees: 22.CertiScation:
(ifwell field,one Wong is sufficient)
Signature of ' col ell ntractor D
fi.Is(are)the well(s): ermanent or ❑Temporary By signi„g thisjbm4 I fib,cerp fy that the well(s)was(were)constructed to accordance
with 15A NCAC 02C.0I00 or 15ANCAC 02C.0200 Well Corium ion Standards and that a
7.Is this a repair to an existing well• Oyes or i 7!l o copy of this record has been provi&d to Me well owner
If this is a repair,fill out known well construction information and ezphmn the natwe ofthe ,
repair Larder#21 rmarks 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 multiple tryechon or not-water supply wells ONLY with the sane construction,you can
submit one form SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: l � A) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if akfferennt(-mnple-3(a)20 'and 2@100') construction to the following:
10.Static water level below top of casing: �(l A) Division of water Quality,Information Processing Unit,
If water level is above casing,uve"+" 1617 Manz 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
Rotary Rota above, also submit a copy of this form within 30 days of.completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground InjectiotL Control Pwgram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) (a 0 Method of test: Blowing-Rig 24c.For Water Sunaly&Injection Wells: In addition to sending the.form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chlorine 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
I