GW1-2022-10629_Well Construction - GW1_20221122

W Lt LL UU1N SI MU L1,1UN RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts F14,ROM TO
To DFSCRffTION
Well Contractor Name it Oft
NCWC 2028-A ft ft f
NC Well Contractor Certification Number
15.OUTERCASING ormnl6.casedwells ORLiNER d bk
FROM TO DIAMETER TfUCKNrec MATERiAI
Ferguson's Well and Pump, LLC ft ` in. S C 5 PD-
company Name 16.INNER CASTING OR TUBI NG: dosed
! /� FROM TO DIAMETER THICKNESS MATERIAL
L Well Construction Permit#:_ �"l �l I ft ft in.
List all applicable well eonst--ion permits(I.e.Coto*,State,Vwiance,etc.)
tt ft is
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM To DIAMETER SLOT SIZE THICIagM MATERL41
❑Agricultural ❑ pal/Public ft. ft in
❑G m eotheral(Heating/Cooling Supply) esideatial Water Supply(single) t k' ft. in.
❑Industri.&Com iercial ❑Residential Water Supply(shared) 18.GROUT _
❑lrritics
FROM TO MATERIAL EMPLACEMENT METHOD A AMOUNT
Non-Water Supply Well: 0 ft 20 IL Concrete Gravity-Flow
ft ft
OMonitoring ❑Recovery
Injection Well: ft &
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/G11AVEL PACK. e
EMPLACEMENT METHOn
❑Aquifer Storage and Recovery DSalinity Barrier FROM To I MATERIALft. ft, ,
❑Aquifer Test ❑Stormwater Drainage R ft
DExperimental Technology ❑Subsidence Control
29:DRILLING LOG:attach adatToYtiii duels if necessary)
❑Gwthtamal(Closed Lwp) ❑Tracer mom TO DESL'REMON color,hardness,saur«Ie etc
❑Geothermal(Heatin hn Return) ❑Other(explain under 421 Remarks) I �ft ft
ft �7 ft Q�
4.Date Well(s)Completed: Well ID# ftf/!,1 ft
/S�a.Well Location: t fG V ft
(olA1f Lp Jos�l6� Lr(/L h ft ft
FacilityltAvner dame Facility ID#(if applicable) C""'� - r. A t y
ft ft t.aE. s .""'
`mAtsl2,- j I ` 753 & ft pV 2 202
Physical Address,City,and Zip 2L REMARKS
c9unty Parcel Identification No.(PIN) +
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
l v 1 2,� Zug " W
Si of 'tied Well Contrac
6.Is(are)the well(s): ermanent or ❑Temporary gy st this for;I hereby car*that the well(s)was(were)crostrrrcted in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing we1L• Dyes or o copy of this record has been provi&d to die well owner.
If this is a repair,fill out b-m well construction hrformrQJlon mid explain fire nature of the
repair order#21 remaks section or on the bads of thtsform 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 muldpie hgectior or non-water supply wells ONLY with the same con srudion,you cat
submit one fonx SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 4 4 (B,) 24- For All Wells: Submit this form within 30 days of completion of well
Fo multiple wells list all depths VfaVerew(example.3@200'and 2@1001) construction to the following:
10.Static water level below top of casing: �f� (ft,) Division of Water Quality,Information Processing Unit,
If water level is above cashtg,use"+" 1617 Matz Service Center,Raleigh,NC 27699-1617
j
11.Borehole diameter•. _ (in.) 24b.For Injection 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: wnstructiun to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injectio&Control Piogram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Blowing-Rig 24c.For Water Supply&Iniectiaa Wells: In addition to sending the form to
—t9 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 tol the county health department of the county
where constructed
f
Form GW-1 - North Carolina Department of Environment and Natural Resources-Division of Water(�Wity Revised Jan.2013