GW1-2022-10549_Well Construction - GW1_20221121

WILL l:U1N J 1 KU U'H1j1V_K11U UKD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
BobbyW. Potts 14.WATER-ZANEs
FROM TO' DESCREMON
Well Contractor Name ft 'ft
NCWC 2028-A tt 3 S ft
NC Well Contractor Certification Number IS.OUTER CASING(for ntalti-cosedwdls ORLINER d ble
FROM TO Drer,,rrrrru Tfitr•rrivrM MATERIAL
Ferguson's Well and Pump, LLC 0 tt S I in. 0 .
Company Name 16 INNER CASING OR TUBING. dosed-lob
,^ FROM TO I DIAMETER I THICKNESS MATERIAL
L Well Construction Permit#: 2 D It - b y l a U: ft ft. irL
List all applicable well cwutruction pernuts(i.e.County,State,Vw imrce,etc.) ft in
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE TfUCKNM MATERIAL
❑Agricultural ❑ blic ft. ft
m in
❑Geotheral(Heating/Cooling Supply) esiWater Supply(single) ft ft in.
❑lndustnal/Commercial ❑Residential Water Supply(shared) I"GROUT _
FROM TO MATERIAL EMPLACENW4T METHOD&AMOUNT
Non-Water Supply Well:
❑ aura 0 rt 20 ft Concrete Gravity-Flow❑Monitoring []Recovery ft ft
Injection Well: tt ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/G1IAVEL PACK e
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL 5ei AcnmNT mvmoDft fat w
❑Aquifer Test ❑Stormwater Drainage g ft
❑Experimental Technology ❑Subsidence Control
X DRILLING LOG:2ttMfi additional sheets H
❑Geothermal(Cluscd Luup) ❑Trautw FROM TO DFSLV1M0N tutor.hardness,Witroclt m etc
❑Geothermal(Heatin Coohn Return) ❑Other(explain under#21 Remarks) A ft ft 02 k
^ uX
4.Date Well(s)
ft(s)Completed: Well ID# ft ft
d C
Sa'Well Location: 019 Ct ft e r-
trtltiv� ft ft
Facility106nerName Facility ID#(if applicable)
ft ft �C ;sCt Ate"'
�7/�p,�� s - 7
m t C n ��-�n e rij j�t. jQ S6 U t U t / 06ND ft ft
Physical Address,City,and Zip
21.REMARKS
lb e ( -7 114 3�
County Parcel Identification No.(PIN) r - '3:1�� i'i::':s d:.=t 1.0
56.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 2L Certification:
(ifwell field,one Wong is sufficient)
c1 it
N 038 3/rC/1/1/9 W /A
Si of fled Well Contras r f<
6.Is(arc)the well(s): zK manent or ❑Temporary By signas this form,1 hereby certify that the wefi(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
7.h this a repair to an existing well: Oyes or C33Vo copy of this record has been provi&d to the well owner.
Ifthts is a repair,frll out known well construction mformation and erplavt the nature ofthe
repair under#21 rettmdts section or on the back 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
S.Number of webs constructed: construction details. You may also attach additional pages if necessary.
For nwlhPk vyectfon or nary-water supply wells ONLY with the same cotraTruc(iort,you can
subrtut oneform SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 3-5—l (ft) 24a. For Ali Wells: Submit this form within 30 days of completion of well
For multiple wells fist aU depths tf different("arnple-3@200'and 2@1001) construction to the fbllovt'ing:
10,Static water level below top of casing: (,go A) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Matz Service Centel,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 Well construction method: Rotary construction to the follou-ing:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injecting Control Pkogram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-16M
13a.Yield(gpm) Method of test: Blowing-Rig 24c.For Water Sunnlly&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.Disinfection type: Chlorine Amount: OZ. completion of well construction to the(county health department of the county
where constructed.
Form GW-I - North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013