GW1-2023-02037_Well Construction - GW1_20230303

wr.LLwill 1KUL11VA Kt4CUKII For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: '
Bobby W. Potts - 14..WATER-ZO1!IE%
Atom co : , DESCRIPTION
Well Contractor Name A ooft A Yo ft
NCWC 2028-A .
. - 2�Y`t c O ft • "
NC Well Contractor Certification Number • 15:O TIER G mida-asedwells)OR LINER(if appI1cabie)
. FROM TO DIAMETER MUCHNESS ma
Ferguson's Well and Pump, LLC e) ft (0$ " f IA3 ilL 2/ef��S r'ec5/, a/
Company Name . • 16.INNER CASING OR G.(Aeutlhe mil dosed oOp)
.f PROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ti.b o a -.6¢.4(e ( ft ft in.
List all applicable well construction permits(r.e.County,State,Variance,etc). - .
f. ft in
•
3.Well Use(check well use): 17 SCRFEiV
Water Supply Well: PROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft ft .in.
❑Agricultural ❑ Public _
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft in 1 ,•
❑lndustrial/Commercial ❑Residential Water Supply(shared) ,10..GRt)IIT.. - . _ ,
PROM TO MATERIAL ' EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20 ft" Concrete Gravity-Flow
Non-Water Supply Well: • f
ft ft
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 1.9..SAND/G11AVEL PACK;t3f applicable)
PROM TO MATERIAL EMPLACEMENTltfKrHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft: .. ' '
❑Aquifer Test ❑Stormwater Drainage .ft ft
❑Experimental Technology ❑Subsidence Control
.2&DRILLING LOG(ittach adiilseal sheets ift ar9)
❑Geothermal(Closed Loop) ❑Trader PROM TO DESCRIPTTON(color,hardness,soll/toca type,grain sae,etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ( ft 70 .ft . p/ ��
�/ 2 � ft ft 1.1
4.Date Well(s)Completed:p(/iZ3 o't/Well ID# _a ft Sft- (/I/'®c �'1�
5a Well Location//:�Y ! /01 ft '(Os ft . (J'r G( W/t f`Ct
a-�f')to l,� ?snerto ft ft
Facility/Gamer Name Facility ID#(if applicable) ft ft ` •
3 ga n Nell) I e e ceb1'/-r fiky h - - ft ft
Physical Address,City,and Zip
21.REMARKS R t') r, L2
61.,, h - $79 j15aa38 ..:ri
County Parcel Identification No.(PIN) L : ,;.;,•r,T^n'
ltli 1JV�','01%1.3
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certifca:on:
(if well field,one las/long is sufficient)
3343g'at 7r 6O'/'g tN ga°e/3'_D, e/3 " w � i/ , tAI , 7__-_---_--
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•
��� Signature ofC .A.ed Well Co,�6fracto DadZVA3
6.Is(are)thewell(s): Dl�r ent or ❑Temporary
By signing this form,I hereby cer*that the wen(syswas(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well CosrbuctionStandards and that a
7.Is this a repair to an existing well: •❑Yes or P3'io copy of this record has beenpravided to the well owner.
If this is a repair,fill out blown well construction information and explain the native of the •
repair under#2I remarks 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 of well
8.Number of wells constructed: / construction details. You may also attach additional pages if necessary.
For multiple irgectian or non-water supply wells ONLY with the same corsbvaian,you can
submit onefom �t SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: • 9l/S (g,) 24a. For All Wells: Submit this form within 30 days of completion of well
For rmihiple wells list all depths Vcreenent(example-3@200'and 2QI00') construction to the following:
10.Static water level below top of casing: R 0 (ft) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
1L Borehole diameter --._ 6 (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: ry construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injectiop Control Program,
FOR WATER SUPPLY�WryELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ...3(") Method of test: Blowing-Rig 24c.For Water Sum &&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 OZ. completion of well construction to the county health department of the county ,
where constructed
Form C-W-1 - North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013 _
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