GW1-2022-10521_Well Construction - GW1_20221121

WEI L UUMIRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts 14.W4TER7.ONES
FROM TO DESCRIPTION
Well Contractor Name ft'
t ft
NCWC 2028-A ft Am ft
NC Well Contractor Certification Number 15.OUTER CASING fort adffi•a�edwdla OR LIN d ER
FROM TO I DIAMFPER TIDCKNFSS MATERIAL
Ferguson's Well and Pump, LLC 0 ft f rAE in, C
Company Name 16.INNER CASING OR TUBIlVG. cased
F O r h G ESrCREEIN
TO DIAMETER TWCKNFSS MATERIAL
L Well Construction Permit#: ci� V a p ft in.
List all applicable well construction permits(i.e.County,State,'Variance,etc.)
ft in
3.Well Use(check well use):
Water Supply Well: TO DIAMEILKI SLOT SIZE TAICKNESS IMATERIAL
❑Agricultural ❑/Public ft ft in'
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single)' ° ft ft m'
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
01mization O
FROM TO MATERIAL EMPLACEMENTMMOD&AMOUNT
7
Non-Water Supply Well: - ft. 20 ft Concrete Gravity-Flow
❑Monitoring ❑Recovery ft. ft
Injection well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GgAVEL PACK e
FROM TO MATERIAL EMPLACEMENTAMMOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft ,
❑Aquifer Test ❑Stormwater Drainage
ft ft.
❑Experimental Technology ❑Subsidence Control 21L DRILLING LOG:attach additimal sheets if necessary)
❑Geuthermal(Clused Luup) ❑Traucr FROM TO DFACIU R'ION color hardness,solurock etc
❑Geothermal(licatmgACooling Return) ❑Other( lain under 421 Remarks) D ft �-- .ft
ft S+ ft
4.Date Wcll(s)Completed: Well ID# ft ftC
5a.Well Location: ft ft r
� 1 1 c
—1•=1'J r�ter\ <<Y,P.F.S(. ft ft ,
Facilitylt�wverName / Facility lD#(ifapplicable)
I _ n ft ft
NA
'4-Q h IC-lJLf U LL ice-4e-/�A ft ft
Physical Address,City,and Zip
2L REMARK5 me U
�nirnmfo e- 9 IN I Jq a q q to
Cqunty Parcel Identification No.(PIN)
56.Latitude and Longitude in degreeshminutes/seronds or decimal degrees: 22.Certification:
(ifwell field,une lat/long is sufficient)
/" Si ed We11 Contractor
6.Is(are)the well(s): 0<1; aWent or ❑Temporary
By signing dtis fornr,I hereby certify that the well(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 well: ❑Yes or IN copy of this record has been provi&d to the well owner.
If this is a repair,fill out known well construction i►g'ormation and exphu n the nature of the
repair um*r#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
9.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For mtdtipk byaction or non-water supply wells ONLY with the same construction,you can
subvt are form SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: Gj S (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi erent(exmnple-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: d�� (ft) Division of Water Quality,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Matz Service Center,Rah*oi,NC 27699-1617
f
11.Borehole diameter. (in.) 241b.For Iniection Webs: 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 follo,%ing:
(i.e.auger,rotary,cable.,direct push,etc.)
Division of Water Quality,Underground Injectiop Control Prpgram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpin) Method of teat. Blowing-Rig 24c.For Water Supply&Iniection Wells: rn addition to sending the form to
0/ the address(es) above, also submit orie copy of this form within 30 days of
13b.Distnfection type: Chlorine Amount: 7 OZ. completion of well construction to the county health department of the county
where constructed.
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Form C-W-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013
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