GW1-2023-02028_Well Construction - GW1_20230303

nyJr,r,,t,Vl\0JLJMUl.1IUII KL+l-.VKU For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts WATERZOMS
FROM TO DESCRIIr1TON
Well Contmoto'rName O ft ft
I
NCWC 2028-A ft ft
NC Well Contractor Certification Number OIITERCASIlIIG, V,Coal VC161 OBLINBR df
. TO DTAMPTER
Ferguson's Well and Pump, LLC FROM ft fc ,n
TgICKNESS MA
r. 5ie-lel
Company Name 16 INNER CASING ORTUANG;Iffaidwrpta damd-Inimi
F FROM TO DIAMETER THICKNESS MATERIAL
2.Wen Construction Permit#: Ua 3 r U Uc).1 N' ft ft in.
List all applicable well construction pemtits(t.e.Connry,State,Vananeee,etc.).
ft ft in
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER I SLOT SIZE I TMCKNMS3 MA7ERL4L
❑Agricultural ft ft is
❑Mtmr�,igal7Public
g Supply) = Supply( gle) ft ft in
❑Geo al(Hen Coolie Su 1 estdential Water son
Efndustrial/Commercial ❑Residential Water Supply(shared) 18-(R OPT.. _
FROM TO MATERILAL EMPLACEMEiTMETHOD AMOUNT
❑Itri ation
f
Non-Water Supply well: t. 20 Concrete Gravity-Flow
• ft ft
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19..SAND/GRAVZI:'PAC$
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM
ftTO- ft: MATERIAL EMPLACEAtELVTA.frmb
❑Aquifer Test ❑Stormwater Drainage R ft
❑Experimental Technology ❑Subsidence Control
2tLDRII:I;II!1GZOG 4ttadi'addwmoidh#tedsff
❑Geothermal(Closed Luup) ❑Trau:r FROM I To DESCRIPTION cdw bardn sotlkwk ctc
❑Geothermal(Heating/Cooling Return) -00kher(explain under#21 Remarks) 1 11 & O .ft ?
ft ft
4.Date Well(s)Completed: Well ID# 19 ". ft �'.
ec
Sa.Well Location: tZ ft �
tl) K.t�.11tlY�e�� ttt(rs ft ft — — ,
Faciiitg/Owner Namc Facility ID#(if applicable) ft. IL
ft ft
Physical Address,City,and 29p 2L REMMM
County Pamel Identification No.(PIN)
5b.Latitude and Longitude in degreeshumutes/seconds or decimal degrees:
(if well field,one lalAong is sufficient) p 22.Certification:
S®3a 03`fit �K9. N V-01-10 'Vx 7/ljQ " W ;2 A/2 31
s f Well for Date
6.Is(are)the weIl(s): ermaneat or ❑Temporary
By�g�8 Tomb 1 hereby certr:jy that the weA(s)%was(were)constricted in accordance
-' with 15A NCAC 02C.0100 or ISANCAC 02C.0200 Well ConstrwfionStaudardt and that a
7.Is this a repair to an existing will: ❑Yes or 0 copy ofthis record has been provi&d to the well owner.
1f this is a repair,fdl ata lawwn well construction brformalion and eiplain the native ofdw
reparr wider#21 rmarhs section or on the bark of dwfmm 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 muhfple hgechm ornm-water supply wells ONLY with thesaute consbudion,you can
sub»w aneform / SUBMITTAL INSTUCTIONS
9.Total well depth below land surfaces. `7 0 S (R.) 24a. For All Wells: Submit this form within 30 days of completion of well
For nn&pk wells list all depths if dV'"od(ex wk-3@200 and 2Q100� construction to the following:
10.Static water level below top of casing: /a (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" -T° 1617 Mail Service Center,Raleigh,NC 27699-1617
1 L Borehole diameter. _ (in.) 24b.For Iniedion Wells: In addition a,to sending the form to the address in 24
Rota above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ry construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground InjectiogControl Pnpgram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 2'f699-1636
t Blowing-Rigc. oaeuomi&Injection Wells: In addition to sea
13a.Yield(pin) Method of test: 24 F r Water S
. ding the form to
the address(es) above, also submit one copy of this form within 30 days of
-13&Disinfection type: Chloride Amount: oz. completion of well construction to thel county health department of the county
where constructed.
i
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013