GW1-2022-10541_Well Construction - GW1_20221121

W1t.L1,l:U1Va'1KUU,I,1U1N KEC;UKU For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts U WATMIZONFs
FROM TO DESCRIPTION
Well Contractor Name
NCWC 2028-A it ft
NC Well Contractor Certification Number IS.OUTERCASING formalti- edRells URLINER rf bk
FROM TO DIAMETER' THICKNESS MATERL►L
Ferguson's Well and Pump, LLC it ft. �� i
Company Name 16 G ORTUBIlYG1- ,4
FROM I TO DIAMETER. THICKNESSS MATERIAL
2.Well Construction Permit#: eZ a — S 7 ft ft in
List all applicable weft constriction perncts(Le.County,State,Vorimree-etc.)
ft ft j in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM To DIAMETER SLOT SIZE THICKNESS MATF.RLAL
❑Agricultural ❑ pal/Public it ft in i
❑Geothermal(Heating/Cooling Supply) QKesidential Water Supply(single) R It. m
❑Industrial/Commercial ❑Residential Water Supply(shared) 1&GROUT.
FROM TO MATERIAL EMPLACENT METHOD lot AMOUNT
Non-Water Supply WWell: �
❑lint Wain ME
f` 20 ft tY Concrete Gravity-Flow
❑Monitoring ❑Recovery ft ft
Injection Wen. ft ft
❑Aquifer Recharge Cl Groundwater Remediation 1%SAND/GRAVEL PACK e
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ITO MATERuL EMPL ACEAU NT 11tETHODft �
❑Aquifer Test ❑Stormwater Drainage R ft
❑Experimental Technology ❑Subsidence Control
21L DRILLING LOG.attach add;tii d if
❑Gcuthetmal(Clwed Ltwp) ❑Tracer FROM TO DES04MON color hardaML sottmxte 011a,grab A2e,etc
❑Geothermal(Ileatin Coolin Return ❑Other(explain under#21 Remarks) 1 0 ft ft
4.Date Well(s)Completed: ���C 7/L Well EM ft ft
Sa.Well Location: f R ft t
ft. ft
Facrlity//dwncr.Na/m'c Facility 1D#(if applicable)
ft ft -..,s g -
ft
/!D// K/!L�/� �/3i/!r y/Z� ,Gf/[Itil�l�'!//�I► p�p 7z ft F
Physical Address,City,and Zip 21.REMARKS
el* 7J1-1-?9 37�.�- s„�?r.J9ev:g Urea
County Parcel Identification No.(PIN) - +
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lWong is sufficient)
3 5"qSz'/_/ g( IN N ga 0,4 T 4�e d���'_W
� Signature of 5cd Con for
6.Is(are)the well(s): �ermancnt or ❑Temporary
By signing this Janis,1 hereby certify' that the wells)was(were)cautructed in accordance
with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Constnrcam Staidcvds and that a
7.Is this a repair to an existing well• ❑Yes or RNIV copy of this record has been provi&d to die well owner.
If this is a repair,fill out brown well construction hrfornration and explain the nahav oftare
repair under#21 ranarks section or on die back of zW fwm 23.She diagram or additional well details:
You may use the back of this page to iprovide additional well site details or well
8.Number of wens constructed: construction details. You may also attach additional pages if necessary.
For inuldple hyection or non-water supply wells ONLY with die same consruchan,you can
submit oneform SUBAIMAL INSTUCTIONS
9.Total well depth below land surfacca. (R,) 24a. For An Wells: Submit this form within 30 days of completion of well
For mubple wells list all dep&s tf do'erad(example-3@200'and 2 r@100') construction to the follo-wing:
I
10.Static water level below top of casing:—�Q (g) Division of Water Quality,Information Proceasmg Unit,
If water level is above casing,use"+" 1617 Matz Service Center,Raleiggb,NC 27699-1617
11.Borehole diameter. _ (ID.) 24b.For Inieetion Wens: In addition to sending the form to the address in 24a
Rota above, also submit a copy of this forest within 30 days of completion of well
12 Well construction method: Rotary construction to the follo-Aing:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injectio#Control Prpgram,
FOR WATER SUPPLY WELLS ONLY: 16M Mail Service Center,Raleigh,NC 27699-16M
i
13a.Yield(gpn) -S Method of test Blowing-Rig 24e.For Water Supply&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: Chlorine Amount: , , OZ, completion of well construction to thel county health department of the county
where constructed.
Form OW-1 North Carolina Department of Emriromunt and Natural Resources—Division of Water Quality Revised Jan.2013
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