GW1-2022-10528_Well Construction - GW1_20221121

WELL LU.NS'1KUl Tft)N KLtC()KU For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts 14.WATM-7A)IvEs'
PROM TO V , DFSCRIPITON
Well Contractor Name ft ft.
NCWC 2028-A ft tt
is.OUTERCASING ormniti adwella ORLiNER rf Me NC Well Contractor Certification Number 5FROMTO
T1nCF7gM MATERIAL
Ferguson's Well and Pump, LLC (� t�S in. 216,/2S ��Company Name ASING OR TU>IIlVG dosed-lou
^ hTO DIAMETER 7mra NESS MATERIAL
2.Wed Construction Permit#: QQal [Jo5u . ft in.
List all applicable well construction pemets(xe.Cowtty,State,Yariame,etc.)
ft3.Well Use(check well use):
Water Supply Wed' I DIAMETER I SLOT SIZE 1 THICIQSFSS I MATERIAL
❑Agricultural ❑ pal/Public ft ft in
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft m
❑Industrial/Commercial ❑Residential Water Supply(shared) 1&GROUT
FROM TO MATERIAL Del ACEMENT METHOD a AMOUNT
0hriRation
Non-Water Supply Well: ft.. 20 Concrete Gravity-Flow
ft ft
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/ VSL PACK e
FROM TO I MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft iti`
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft ft
20.DRILLING LOC.G:attadi^addititind sheets jf
❑Gootheamal(Closed Luup) ❑Tracer FROM TO DESC'RIMON color butnesi6 solltrocit etc
❑Geothermal(HeatingACoolmg Return) ❑Other(explain under#21 Remarks) ft 0 1L
�(/?'�/����� 19 4.Date Wcll(s)Completed: 17r-rf��=Well ID# it O tt
ft
L aY
5a Well ft Location: ft ft
.Iqs
11 fay Ltnt _t/IVEIS�J✓Nr��s ft ft
•--ac�ryT/O(vnerName Facility lD#(if applicable) ^" 924ft ft U _ 4
Physical Address City,and Zip 21.REMARKS
t,r►�nmbP g13-5 Ll N C U47 PmCwW. Urfs
County Parcel Identification No.(PIN) DVQ/3OG
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 Certification:
(if well field,one laMong is sufficient) _
DSO.
�A . WSr o e rtificd Well Contractor
6.I.(are)the well(.): ernoauent or ❑Temporary
By sigrmng this form,I hereby cash;fy that the weA(s)was(were)casstrected in arcordarrce
with ISA NCAC 02C.0100 or 15ANCAC 02C.0200 Wdl Construction Standards and that a
7.h this a repair to an existing wed: Oyes or o copy of this record has been provi&d to die well owner.
If this is a repair,fill out bwxn well constuction b1 omw on and erplai n the nature of the
repair wider#21 roxm r section or on fire 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 byechorn or non-water supply wells ONLY with the smite construction you ca n
submit oneform SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: !'S (O,) 24a. For Ad Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdr ferent(exmnple-3Q200'and 2@100� construction to the following:
10.Static water level below top of casing: Y`, (g) Division of Water Quality$Information Processing Unit,
If water level is above casing,use"+" 1617 Matz Service Center,Raleigh,NC 276994617
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 fulloving:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injectiop.Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Blowing-Rig 24c.For Water Suonly&Injection Wells: rn addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
Il3b Disinfection type: Chlorine ,��t oZ. completion of well construction to the county health department of the county
where constructed
Form OW-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013