GW1-2022-10524_Well Construction - GW1_20221121

W hLL l U1Na'1'RUU110N Rl+.CORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts 14.WATER ZONES
FROM TO DESCREMON
Well Contractor Name ft O ft i
NCWC 2028-A % ft
NC Well Contractor Certification Number 15. efla OUTER AS1NG ow=4 ealed.w OR LINER d ble
FROM TO DTeAd TER I nUCE NESS I MATERIAL
Ferguson's Well and Pump, LLC ft ft t w V
Company Name 16.INNER CASING OR TUBING. dosed
FROM TO DIAMFTFR I nHVENM I MATERIAL
2.Well Construction Permit#: pl Q� o� - 00�a�-� ft ct � in.
List all applicable well construction penults(i.e.Cotouy,State,Variance,etc.)
ft ft in
3.Well Use(check well use): 17.5CR&
Water Supply Well: FROM TO DIAMETER; SLOT SU I TMCRW_4N I MATERL4L
❑Agricultural ❑�Municipal/Public ft ft in
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft m
❑Iadustrial/Commercial ❑Residential Water Supply(shared) 18.GROAT
FROM TO MATERIAL EMPLACEMENT METROD&.AMOUNT
❑lira Lion ft 20 ft Concrete Gravity-Flow
Non-Water Supply Well: 0
❑Monitoring ❑Recovery ft ft
Injection Well: & &
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK e
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft TO ft
EMPLACEMENT?.=OD
,
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control i
20.DRILLING LOG.art ch additional shoats it
❑Geuthcrmal(Clused Loup) ❑Tracer FROM TO DESt RiMON color hardness,solbTocit ffi etc
❑Geothermal(Heating/Cooling Return ❑Other(explain under#21 Remarks) 6
ft ft l
.-0 ft ��
4.Date Well(s)Completed: Well ID# ft ft
z° t C
Sa.Well Lunation: ft ft I e
l� k"� 'V r IM.EN (tJ & ft
Facility/tamer Name Facility M#(if applicable) `• �
ft ft
G
A 2 [[r1511z ;!,& 7�LS ft ft
cal Address,City,and Zip 2L REMARKS •ror.ter_ Until
6uACOmb�L 10-76a P 7o q D_f Dt01Q;30G
County Parcel Identification No.(PIN)
56.Latitude and Longitude in degreeshminutes/seconds or decimal degrees: 22.Ceriificati n:
(ifwell field,one lat/loag is sufficient)
' 5 46V r, N z'V50 737i If9 / W
Signature of CertiS ell Contra or Da
6.Is(are)the Well(s): ermanent or ❑Tetnporery By$19-g this arm I hereby cer*that the well(s)-was(were)constructed in accordmrce
with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Wdl Construction Standards and that a
7.Is this a repair to an existing well: Oyes or QNo copy of this record has been provi&d to the well owner.
If this is a repair,fill out brawn well construction Wormation and explain the nivu a of the
repair under#21 ranarb section or on the back of dusform. 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 a9ection or non-water supply wells 0NLlr with the saute construction,you con
sub"*�f� SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: S (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths Tf d fferenf(example-3@206
and 2@100') construction to the folloRtiag:
10.Static water level below top of casing: J(/ (g,) Division of Water Quality Information Processing Unit,
If water level is above casing,use"+" 1617 Mail 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 form within 30 days of completion of well
12 Well construction method: Rotary construction to the follo-Aing:
(i.e.auger,rotary,cable,
,direct push,etc.)
Division of Water Quality,Underground InjectiogControl Prygram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cent ,Raleigh,NC 27699-1636
13a.Yield me-For Water Supply&Iniection Wells: In addition to
(gp )_�_ Method of test: Blowing-Rig 24 sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chlorine Amount:T� 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 Ian.2013