GW1-2022-10533_Well Construction - GW1_20221121

WEI L C:OASIRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts 14.wAT ZONES
FROM TO DESCRIPTION
Well Contractor Name ft ft
NCWC 2028-A ft 3 ft
NC Well Contractor Certification Number 15 OUTERCAS G atstdti-easedwdls OR LINER d
Ferguson's Well and Pump, LLC FROMct TO DIAMETER TffiCKNETS MATERIAL
D
Company Name 1&MNER CASING OR G.
< FROM TO DIAMETER TffiCKNFSS MATER AL
2.Wei Construction Permit#: ' Z b ^ G 6 3/ Q. ft ft I in
List aH applicable well cwrsintction pentdfs(t.e.County,State,'Variawe,etc.)
ft ft in
3.Well Use(check well use): 17.SCREEN
Water Supply Wen: FROM TO DIAMETER! I SLOT SIZE THICKNESS MATERIAL
OAgricultural DMum�ipaUPublic ft ft in
OGeothermal(Heating/Cooling Supply) estden dial Water Supply(single)a ft ft ur'
Dlndustrial/Commercial OResidential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENTT METHOD tit AMOUNT
Obi lion 0 ft 20 rt Concrete Gravity-Flow
Non-Water Supply Well: - g. ft
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19 SAND/NE-1 PACK e
FROM TO MATERIAL EMPLACIIMIZNTAO'1fiOD
❑Aquifer Storage and Recovery DSalinity Barrier ft. K
OAquifer Test ❑Stormwater Drainage
fc ft.
❑Experimental Technology ❑Subsidence Control
X DRILLING LOG.athtch addifimal afieetsif P
OGeuthormal(Clused Loup) ❑Traces- FROM TO DEst'RIP O color hardnm sdUnwIt Ott,V61h die,etc
OCreothermal a4catingCooling Return ❑tither(explain under 421 Remarks) t9ft ft t
ft ft
4.Date Wells)Completed: Well nm 30
Ys
ft
52.Well Location: e
r< ft
1✓a4i���.�� �� ft ft
Faci1ity10suner�Iams , Facility ID#(if applicable) ft ft
ft it —.•i V
Physical Address,City,and Imp 21.RE11f4M
C1n�6,t Cfl.����.Sci3s NOV 2 i ZUZZ
Cpuny Parcel Identification No.(PIN)
ter. UM
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: "
(dwell field,one!oblong is sufficient) 22 Certification: �P.��
J signanfz've c Ked Well Con r
6.Is(art)the well(a): ..cat or ❑Temporary BY stgrung this form I hereby certsjy,that the well(s)was(were)cars&wted Ise accordmrce
with ISA NCAC 02C.0100 or 15ANCAC 02C.0200 JEW Construction Standards and that a
7.Is this a repair to an existing weft Dyes or o copy of this record has been provi&d to the well owner.
1f this is a nap*frll out brown well construction n%rbmxdion and eVhdn the nature of the
repair under#21 renarks.section or on the back of Bus 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 irgection or non-water supply wells ONLY with the same oonstruelion,you can
subs*oneform SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: %0 S (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For mutiple wells list all depths ifdr femrt(eamnple-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: A (R,) Division of Water Quality,Information Processing Unit,
If water level is above casmg,use"+" " 1617 Matz Service Center,Raleigh,NC 27699-1617
I
11.Borehole diameter (in.) 24b.For Infection Wells: In addition to sending the fort to the address in 24a
12 Well construction method: Rotary
above, also subunit a copy of this form within 30 days of completion of well
Const action to the following:
(i.e.auger,rotary,cable,direct push,etc.)
DhIsion of Water Quality,Underground Injecting Control Prpgram,
FOR WATER SUPPLY WELLS ONLY: 16M Mail Service Center,Raleigh,NC 27699-16M
13a.Yield(gpm) Method of test: Blowing-Rig 24c.For Water Simply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit otic copy of this form within 30 days of
Chlorine completion of well construction to the county health department of the county
I136 Disinfection type: Amount-
where OZ.
where constructed.
Form OW-1 - North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013
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