GW1-2022-10515_Well Construction - GW1_20221121

W LLL UUNSIRUU11UN-REUUKD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
4+ I*WATER'•ZONES
Bobby W. Potts FROM TO DESCRIPTION
Well Contractor Name ft ♦t!Q ft
NCWC 2028-A ft O ft
NC Well Contractor Certification Number 15.OUTERCASING fformdti-ca8edweUs ORLINSR d ble
PROM TO DIAMETER TFUCK mec MATERIAL
Ferguson's Well and Pump, LLC o ft tk X5 i- C z/
Company Name 16.INNER CASING OR TUBING. dosed
FROM I TO DIAME7FR THICKNESS I MATERIAL
2.Wen Construction Permit#: Zvz Z 15 /t[�, l) ft ft i.r
List all applicable well construction permits(ae.Cow*,State,YarimiFe,einj
tt ft in
3.Well Use(check well use): 17 SCREEN
Water Supply Wen: FROM TO DIAMETER I SLOT SM THICKNESS MATERIAL
❑Agricultural ❑ cipaLTublic ft ft in
❑Geothermal(Heating/Cooling Supply) C esidential Water Supply(single) r R ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT _
01nigation
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT Non-Water Supply Well: 0ft 20 ft Concrete Gravity-Flow
❑Monitoring ❑Recovery ft ft
Injection Wen: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GPAVEL PACK fif appiticable)
FROM TO MATERIAL EMPLACEMENT 14WMOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft A
❑Aquifer Test ❑Stormwater Drainage
ft ft
❑Experimental Technology ❑Subsidence Control 2a'DRIILING LOG.acts&additiuod shoeft K f
❑Geothermal(Clused Loup) ❑Tracer FROM To DESC[tIPfION color 6ardn sdUrocQ m etc
❑Geothermal(Heating/Cooling Return) DOther( lam under 421 Remarks) D ft O .ft
rz�
4.Date Wells)Completed: ft ft o1�Well IDq ft. � ft G
Sa.Wen Location: ft ft
�- art
w a R JPHnN-'1•hn ft ft
Facility/0wmec/��iame F
/acilityM4(dapptica�bllee) ft ft �a iv.,
)T %se f 'YJLIC�_L Pt(�Ffr —2ap 7TQ _ ft ft NOVA 2 20��
Physical Address,City,and Zip Iv Y
2L REMARKS
l)!dM t �& G4/ lnfo-waaon Pr^%33o�rQ Unt
County Parcel Idenufieation No.(P )
Sh.Latitude and Longitude in degreeshninutes/seconds or decimal degrees: 22.Certification:
(if well field,one latAong is sufficient)
3S°365y///- N A ° at�syy-r W %l e 7 Ap/a A
Sigmture of fied ell ntractor
ti.Is(are)the well(a): L]YerIDanent or ❑Temporary By signiyg this form I hereby cert6 that the we (s)was_(were)constructed in accordance
with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing weEl: ❑Yes or U o copy of das record has been providd to die well owner.
If this is a repair,fill oat known well consdvction bforotation and a wlact the nature ofthe
repair under#21 ranarb 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 byection or non-water supply wells ONLY with the same carstntcfian,you can
subnw oneform / SUBMIWAL INSTUCTIONS
9.Total well depth below land surface: 3/!S ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For rnuMple wells list all depths if di eAW(exanple-3@200'rand 2 a(100D construction to the following:
10.Static water level below top of casing: of(/ (ft) Division of Water Quality;Information Processing Unit,
If water level is above casing,use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. _ (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Rota above, also submit a copy of this fc m within 30 days of completion of well.
12 Well construction method: Rotary construction to the fullo-Aing:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injecting Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Centex,Raleigh,NC 27699-16M
i
13a.Yield Wm) Method of test: Blowing-Rig 24c.For Water Sunoly&Injection Wells: In addition to sending the form to
the address(es) above, also submit otie copy of this form within 30 days of
136 Disinfection type: Chlorine Amount G/ oz. completion of well construction to the county health department of the county
where constructed-
Form C-W-1 - North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013