GW1-2022-10531_Well Construction - GW1_20221121

WELL ULIPA NI XIIJ HUN HE C ORI) For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts ><a wATlzRzox>�s
FROM TO DESCRIPTION
Well Contractor Name fL D &
NCWC 2028-A ft &
NC Well Contractor Certification Number 15.OUTER CASING formniti�ibed.wo OR LINER d
FROM TO DIAMETER THICKNESS MATERIAL
Ferguson's Well and Pump, LLC 4 ft. 0 ft r A we S► 2/
Company Name 16.INNER CASING OR TUBIlVG.(exidimmoulclosed
A /` FROM TO .DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 20 2-2 . U U q 3 q ,t ft ;R
List all applicable well construction pervdis fl.e.Comm),,State,Yarim cA etc.) ft
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑ micipal/Public ft ft in'
M
❑Geothermal(Heating/Cooling Supply) or-idential Water Supply(single) ft ft in'
❑Industrial/Cornmercial []Residential Water Supply(shared) 18.GROUT _
❑II71 atiOII
FROM TO MATERIAL BeIACEWEN'TMEMIOD&AMOUNT Non-Water Supply Well: Oft 20 ft Concrete Gravity-Flow
❑Monitoring ❑Recovery ft. ft
Injection Well: ft ft
[]Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK. e
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM fL TO- MATERIAL Dee ACEIIIE.NT MFIHOD
❑Aquifer Test ❑Stormwater Drainage g ft
❑Experimental Technology ❑Subsidence Control
2&DRILLING LOG.attach addilimal ahaets if t
❑Geuthermal(Closed Loup) ❑Tracer FROM TO DESL'ItWnON color hardn sofUroclt etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) U ft ft
ft ft
4.Date Wells)Completed: Well IDN ft
C
Sa.Well Location:
R S ft r
ft &
Facility/Owner Name Facility 1D#(if applicable) `
L'
//��
ft ft
a0 rore6� 0-rts IC ` f t V l�f SV1P1/1�1e 'P ft ft NOV 2 12022 Physical Address,City,and Zip 2L REMARKS
�7tAAelQMin a 1n(Orlil'a%ia-1pro+ad9 =1
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
IS a35 39, '?VAV e 32AT,GVKY r W '
Signature o er ied ell CAtFactor
6.Is(are)the well(,): ermanent or ❑Temporary
By signing tills fosm,I hereby cerhjy that the well(s)was(were)constructed in accordmrce
with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Will Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or copy of this record has been provi&d to the well owner:
If this is a repedn fill out/mown well construction iryornmion and explain the norme ofthe
repair under#21 rananks section or on the back of thisforw 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 necessmy.
For multiple hyecam or non-water supply wells ONZY with the same construction,you can
submit oneform �- SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For—bple wells list all depths if tkf jerent(--nple-3@200'and 2Qa 100') construction to the following:
10.Static water level below top of casing: SD (ft,) Division of Water Quality;Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 2769911617
11.Borehole diameter: (in.) 24b.For Iniection 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 Weli construction method: Rotary construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Undeigound Injection Control Prpgram,
FOR WATER SUPPLY WRLLS ONLY: 1636 Marl Service Center,Raleigh,NC 27699-16M
13a.Yield(gpm) Method of test: Blowing-Rig 24c.For Water Sonpls&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.DisIDtecdon type: Chlorine Amount: 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