GW1-2022-10550_Well Construction - GW1_20221121

W LLL UUl NIXUU11UN AM cUKU For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts 14.WATERZONES
FROM TO DFSCRtPTION
Well Contractor Name ft ft
NCWC 2028-A ` ft ft r
NC Well Contractor Certification Number M OUTERCASING orm wel4 ORLiNER If bk
FROM I .TO DIAMEM 7SICHt1 FM MATERIAL
Ferguson's Well and Pump, LLC ;in. 2
Company Name 16.INNER CASING OR G: closed ou
< /� ^^ FROM ft ft in TO DIAMEM s TMCSNM MATERIAL
L Well Construction Permit#: AO.A a. 6 y . ft R in
List all applicable well construction penrdts(Le.Cowny,Sfate,,Toriarrce,etc.)
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE I TIIICKNFM I MATERIAL
ft ft in 11
OAgricuitural ❑Munric blic
❑Geothermal(Heab4Cooling Supply) esiC�lf dential Water Supply(single) R ft m
❑Industrial/Commercial OResidendal Water Supply(shared) "L GROUT _
FROM TO MATERIAL EMPLACEMENT METHOD dt AMOUNT
[]Irrigation nte ft., 20 ft- Concrete Gravity-Flow
Flow
Non-Water Supply WeII: �"
❑Monitoring OReoov ft ft
�3`
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/ VEL PACK e
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I To ./ MATERIAL DeLACEMENTAMTHOD
R ft'
❑Aquifer Test ❑Stormwater Drainage g, ft
OExperimental Technology ❑Subsidence Control
21lr2f.
LII!tG LOG.attach additigoal sheetsif
❑Geuthetmal(Closed Loop) ❑Tracer FRTo DESt1tIMON cdo tnrdn soiiVwk etc
❑Geothermal(Hestia Coolin Return ❑Other(explain under#21 Remarks) ft Q (
7S ft a� .
4.Date Well(s)Completed: Well lI?# ft ft C
5a Well Location: g^ ft OS ft
ft
b-� e ft
Facili :Name Facility M#(if applicable) ft ft
3 BAIJW in FAr- S Rd r(f4Ck)Cjr QtTia K ft physical Address,City,and Zip 2L REMARKS
fir, ►�nraY,h a(,� yYSySSNUV 2 1 ZOZZ
CQ;1aty Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degreeshminutes/seronds or decimal degrees: Z2 Certification:
(ifwell field,one latAong is sufficient)
9'N�JA 09 d 4a,s5gq� " W --
��� Si � well for
6.Is(arc)the weII(s): ❑Permanent of ❑Temporary f�I fib,cer*that the well(s)was(were)carshucied in accordance
with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Constrrrcbw Standards and that a
7.Is this a repair to an existing well: ❑Yes or allo copy of this record has been provided to the well owner.
If f is a repair,fill out brown well construction ir¢annafion and eWhrbr the naawe ofthe
repair wader#21 remarks section or on the back of thlsforrra 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 irgeciran or non-water supply wells ONLY with the same coinstrudion,you can
submit one forma �5 SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: �// (fL) 24a. For All Wells: Submit this form uvithin 30 days of completion of well
For multiple wells list all depths ifo6 erent(esmnple-3@20 'and 2Q100� construction to the following:
10.Static water level below top of casing: 00 Division of Water Quality;Information Processing Unit,
If water level is above casing,use"+" 1617 Marl Service Center,Raleigh,NC 2769961617
11.Borehole diameter. _ (in.) 24b.For Infection Wens: 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 Injectiog Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cent'I,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Blowing-Rig 24c.For Water Sunnly&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: )Z. completion of well construction to the'county health department of the county
where constructed
Form GW-1 - North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013