GW1-2022-10534_Well Construction - GW1_20221121

WMAL LVAhN1KUl;1lUJN KIP I:UKU For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts 14.WATERZZONES
FROM TO DESCRIPTION
Well Contractor Name ft ft
NCWC 2028-A ft qAfift
NC Well Contractor CertifrcationNumber 15.OUTER G or�nitieased:wella URI:INER d bk
FROM TO DIAMETER THICKNESS MATERIAL
Ferguson's Well and Pump, LLC ft ft in. kC /Z2
Company Name 2 16 ER G OR G. closed
�/O -a0 o a 3 FROM TO DIAMETER THICKNESS MATERIAL
L Well Construction Permit#: ft ft I in
List all applicable well crostruction perndts fl e.Corody,State,Variance,etc.) ft ft I in
3.Well Use(check well use): i
17.SCREEN
Water Supply Well: FROM TO vL1NWITR SLOT SIZE THICKNESS I MATERIAL
ft ft inl
❑Agricultural ❑Munici lie
❑Geothermal(Heating/Cooling Supply) esidenti Water Supply(single) R ft in.
❑lndustriaVCommercial ❑Residential Water Supply(shared) 18-GRO TT _
FROM TO MATERIAL EMPLACENffiVT METHOD&AMOUNT
Non-Water
❑ 0 ft 20 ft Concrete Gravity-Flow
,Slpply Well: ft ft
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL.PACK . e
FROM TO MATERIAL EMPLACENIENT hMMOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft
❑Aquifer Test ❑Stormtwater Drainage h. ft
❑Experimental Technology ❑Subsidence Control
2&DRILLING LOG:(attach am abee6s if
OGeuthetmal(Clused Luup) ❑Tracer FROM TO DES0tWn0N tutor hardness,sotlkwk olujrain d2e,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) © ft ft
ft ft
4.Date Well 1D
s)Completed: Well #
ft ft
Sal.well Luca
ft 0� ftrn es n Wt u_r// ft ft
Facility/Owner blame ?J Facil' EX(if applicable) ? ft ft
5 3 - iV CIQVi<ltJ�d�c70 ft ft i
Physic4LAddress City,and Zip 21,REMARIM
04
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if wcll field,one lat/long is sufficient)
�,, N Fol °�27 /3 3,a79-Y rr w -
_� St of cd Wel Contras
6.Is(art)the well(s): L7Permanent or ❑Temporary By signing tins form I fib,certip that the well(s)was(were)constructed in accordance
_/ with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Wdl Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or G3'1Vo copy of this record has been provt&d to the well owner.
1f this is a repair,fill out blown well construction i#bnitation and eplain the nature of the
repair carder#21 ranavb section or on the back of ihtsfbrm 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 agection or iron-water supply wells ONL Y with the same cons&udion,you can
suhnnt areform SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: Sl% (ft) 24a. For Ail Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100� construction to the following:
10.Static water level below top of casing: 30 00 Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Matz Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (in.) 24b.For Injection Webs: In addition to sending the form to the address in 24a
Rotary above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injectiolp Control Pogram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 17699-1636 -
13a.Yield(gpm) 3 Method of test: Blowing-Rig 24c.For Water Slum,&Injection Wells: In addition to sending the form to
the address(es) above, also submit one'copy of this form within 30 days of
13b.Disinfection type: Chlonne Amount: 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 t Revised Jan.2013
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