GW1-2022-10523_Well Construction - GW1_20221121

W Lt LL l:U1NN1KU1;*1'lU.N H 1H CORD For Internal Use ONLY:
TW form can be used for single or multiple wells
I.Well Contractor Information:
Bobby W. Potts 14.WATERZONES.
FROM TO DESCRIPTION
Well Contractor Name ft a D ft
NCWC 2028-A ft. d &
NC Well Contractor Certification Number 15.OUTER CASING Ifffiowr mnl6•caeed wills OR LIlVER if bk
FROM TO DIAMETER THICKNESS MATERIAL
Ferguson's Well and Pump, LLC ft f< f .in. �C 2/
Company Name 16. CASING OR TUBING. dosed
< �1 FROM TO I DIAMkTFR I THICKNESS MATERIAL,
2.Well Construction Permit b G )5 7 R ft E in.
List all opplicable well construction penrcts(te.County,State,Variance,etc.)
ft ft in
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER, SLOTSrLE THICKNESS MATERIAL
OAgncultural ft ft in
❑ cipaUPublic
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) n• ft in!
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT r
FROM TO MATERIAL EMPI.ACEMENTltlMODraAMOUNT
Non-Water Supply Well: � ConcreteGravity-Flow
a ft 20 & Gravi Flow
[]Recovery Recovery ft. ft
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACI e
❑Aquifer Storage and Recovery ❑Salty gamer FROM To MATERIAL n&LACEMENrMErHOD
ft fG
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control h• ft
2&DRILLING adorn adds imal a>eeds if
❑Geothermal(Closed Loop) ❑Tracer FROM TO DES(3WnON color bardn soilhocte d7 etc
❑Geothermal aleatin Coolin g Return) ❑Other(explain under 421 Remarks) ft. Q ft
ft ft
4.Date Well(s)Completed: Well lD# ft ft
Sa.Well Location: ft ft C
� w `
r
�IJ� '2 & ft
Faorhty7Owner Name Facility ID#(if applicable)
I31 ft rn �_�
110Ct4 ✓6rU to ff y$ & ft Zug. a
Physical Address,City,and Zip
� 21.REMARKS
tSL�I/lcaA'1 titP - �GzR�DbS�daS
County Parcel Identification No.(PIN) T
5b.Latitude and Longitude in degmes/minutes/seconds or decimal degrees: 22 Certification +'
(ifwcll field,one lat/long is sufficient) .
N w
erm 4 I A&
si od Well Contractor
6.Is(aft)the well(s): anent or ❑Temporary si this o I here
B3 runB form by certify that the well(s)Vas(were)eonsbwted m 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 20o copy of this record has been provickd to the well owner.
If this is a repair,fill out!mown well construction information and erplabr the nature of the
repair reader#21 rernarkcv section or on the back of thisform 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 iultiple nyecoon or non-water supply wells ONLY with the same awaarr cftn,you can
subout onefo?"t /d SUBMITTAL INSTUC71ONS
2
9.Total well depth below land surface: J%_S (B) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(=a nple-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: Yo (ft) Division of Water Quality;Information Processing Unit,
If water level is above case g,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. _ (in.) 24b.For Iniectlen 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: Rotary construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Dh-blon of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-16M
13a.Yield(gpm) 15 Method of test: Blowing-Rig 24c.For Water Supply&Injection Wells: In addition to sending the.form to
the address(es) above, also subunit orie copy of this form within 30 days of
13b.Disinfection type: Chlodne Amount: 510 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 ,
Q�ity Revised Jan.2013