GW1-2022-10535_Well Construction - GW1_20221121

WL+LLI:UNJ'1'KUt 1UN HIHCOKD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts 14.WATERZMES
FROM TO fDFSCRIPtION
Well Contractor Name ft O ft
NCWC 2028-A n v ft
R
NC Well Contractor Certification Number IS.OUTERCASING(for mnl6 eased wells OR LINER tf bk
PROM TO DIAMEfFR MCKNM MATERIAL
Ferguson's Well and Pump, LLC ft17,2, ft 4 12-4r 5 UcS r2"
Company Name �J 16.INNER CASING OR G. dosed
G-OZ Z GG(O a FROM TO DIAME M THICKNFSS MATERIAL
2.Well Construction Permit M ft g in.
List all applicable well construction pernats fl e.County,State,Variance,etc.)
ft ft in.
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER sLoT srrs I THICKNESS I MATERIAL
ft ft in.
❑Agricultural ❑ pa]/Public
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft It. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL DeLACIIvILN'l'METHOD&AMOUNT
01ingation 0 rt 20 ft Concrete Gravity
Flow
Non-Water Supply Well: ty
ft ft
❑Monitoring ❑Recovery
Injection Well: tt I ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PAClird applicablet
FROM TO MATERIAL EA�LAMMPIT NWIMOD
❑Aquifer Storage and Recovery ❑Salinity Barrier fc f
❑Aquifer Test ❑Stormwatea Drainage
❑Experimental Technology ❑Subsidence Control ft ft
XDRI12MG LOG.(attach additigoal Acets if
❑Geuthermal(Closed Luup) ❑Traucr FROM To DFSI-AUMON color,hardness,soturoc8 die,etc
❑Geothermal(Heatin Coohn Return) ❑Other(explain under#21 Remarks) 6 ft tt
ft ft
4.Date Well(s)Completed: Well IDN R ft
-e C
5a.Well Location: �1 it ft
7&VieV' C Aicr for ft ft
Facility/Owncrr Namc Facility ID#(if applicable) ft ft .a
Ldazz) V�f�/_c/ 987q8 ft ft t
Physical Address,City,and Zip
21.REMARKS
Una
County Parcel Identification No.(PIN) 's r
Cj�llt�i3rJG
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
It
Si ed Well utrac ate
6.Is(aft)the well(s): ermaneat or ❑Temporary
By signing this form,I hereby certify that the well(s)-was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Wdl Construction StwWa dr and that a
7.Is this a repair to an existing well: Oyes or QNo copy of this record has been pravi&d to the'well owner.
If lks is a repair,frll out known well construction irrfornudion and e7lact the nature of the
repair under#21 renalct section or on the bark 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
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple tryeciton or neon-water supply wells ONLY with the sane cons&udion,you can
oneform SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: (B,) 24a. For All Wells: Submit tins form within 30 days of completion of well
For multiple wells list all depths if alfferent(example-3@200 atdd 2@100') construction to the following:
I&Static water level below top of casing: 0 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. _ _ On-) 241b.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.Well construction method: Rotary construction to the following:
(i.e.auger,rotary,,cab
direct push,etc.)
Division of Water Quality,Underground Injection Control Pipgram,
FOR WATER SUPPLY WELLS ONLY: 16M Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) I S Method of test: Blowing-Rig 24c.For Water Supply&Inwenon Wells: In addition to sending the form to
the address(es) above, also submit orie copy of this form within 30 days of
13b.Disinfection type: Chlorine Amount: / )Z. completion of well construction to the county health department of the county
where constructed.
Form M-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013