_Well Construction - GW1_20230315 (74)

W.LLL UUNNI KUUTION Hl;CORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts 14 WATER•
FROM TO DFSCRD�IION
Well Contactor Name ft Eti
NCWC 2028-A ft ft
NC Well Contractor Certification Number 15:OUTEACASING formul&cased;welis ORLINF.R If ble
FROM TO DIAMLRER TFHCIQHESS MA
Ferguson's Well and Pump, LLC ft. ' ft in 2/ r/U I 1P1C5PkL1
Company Name 16.INNER CASING OR.TUBIlVG.(zeaditrM21 clused-l000l
t FROM TO DIAMFTER TmvvwSS MATMUAL
Z Well Construction Permit#: G 6 5'1 3 ft ft in
List all applicable well construction pernrlts(t e.Cotmty,Stale,Variance,etc.) fL fL �
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DLIMETER SLOT SSM I TMCENYM I MATERLAL
❑Agricultural ❑Munici blic ft ft in
❑Geothermal(Heating/Cooling Supply) tdential Water Supply(single) ft ft in.
❑Industrial)Commercial ❑Residential Water Supply(shared) 18,.GROUT _
on FROM TO MATERIAL SMPLACIINF21'f METHOD&AMOUNT
Non-Water❑ aer Supply Well: 0 ft 20 ft Concrete Gravity-Flow
❑Monitoring ❑Recovery ft ft
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/ VEL PACK e
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL DeLACEMIENT117MOD
& fur
❑Aquifer Test ❑Stormwater Drainage ft, ft
❑Experimental Technology ❑Subsidence Control r
20 DRHIJ NG LOG.atta&iddidensl abccfsif
❑Geothermal(Cluscd Loop) ❑Tracer FROM TO DFStIdMON color hardness,soiltroclt sl2e,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) I ft .ft
C� t 0 ft
4.Date Wells)Completed: Well ID# v ft, ft
52.Well Location: S ft ft le—a a ft ft
Facility/OwnerName Facility ID#(if applicable)
ft ft I^
$v2y/P4 `aindLf ied &Sul( P6_715( ft ft
Physical Address,City,and Zip
21.REMARKS. � ;: w
b6d�7906�
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one laMonng is sufficient) / 22.Certification:
3SS�� trYlla'I�S�O N �� � �5�(vt�O/76 W 71A
Signature of ed Well Con for D
6.Is(are)the well(s): erntanrnt or ❑Temporary By signs g this farm,I hereby certify that the wen(s)-was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15ANCAC 01C.0200 Well Constrrxtion Standards and that a
7.Is this a repair to an existing well: ❑Yes or o copy of ft record has been provi&d to the well owner.
Ifthts is a repmr,fill out brown well construction information and explain the nature of the
repair under#21 remarks section or on the bark of thisfoym 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: 1 construction details. You may also attach additional pages if necessary.
For tnu tiple n9ection or non-water supply wells ONLY wtth the same construction,you can
submit onefotm SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 7 ys (a) 24a. For Ail.Wells: Submit this form within 30 days of completion of well
Formuldple wells list all depths ifdifferent(ermnple-3@200'and 2@I00D construction to jhe following:
10.Static water level below top of casing: Y� A) Division of Water Quality,Information Processing Unit,
If water level is above casing,uve"+" 1617 Matz Service Center,Raleigh,NC 27699-1617
i
11.Borehole diameter (in.) 24b.For Inieetinn Wells: In addition to sending the fort to the address in 24a
Rota above, also submit a copy of this form within 30 days of completion of well
i..Well construction method:pu k Rotary construction to the following:
(i.e,auger,rotary,cable,direct push,c[c.)
Division of Water Quality,Underground hijectio&Control Frvgram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigb,NC 27699-16M
24c.For Water Suuoly&Injection Wells: In addition to sea
13a.Yield(gym) � Method of test: Blowing-Rig ding 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 CAW-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013