GW1-2023-02044_Well Construction - GW1_20230303

MULL L UU1V.KIRUC 11UN RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Weil Contractor information:
Bobby W. Potts
FROM TO DESCRIPTJON
Well Contractor Name ft ~ft
NCWC 2028-A " - ft ft
NC Well Contractor Certification Number 15 OUTERCASING `.=altrc scdwells ORLWM d
Ferguson's Well and Pump, LLC FROM ft TO ft DIUA M 6� '�'
Company Name M INNER CASENG OR TIIBING: closed `
�7 h FROM TO DL)AETER TffiCKNFBS
L 2 ft. MATERIAL
2.Well Construction Permit#: q���Q ft in.
List all applicable well catstruchon ^ L�LL�
perndts(ce.Cotorty,State,�arrmtce,etc.).
ft ft in,3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER SLOT M nUCKNFS3 I MAMM41
❑Agricultural ❑Municipal/Public ft ft AIL
❑Geothermal(Heahng/Cooling Supply) ldential Water Supply(single) ft is
e
❑Industrial/Commercial ❑Residential Water Supply(shared) 1&.IRtOUT. _
FROM TO MATERIAL EMPLACnw;rmmoD&AMOUNT
Non-Water Supply Well: 0 Gravity-Flow
When ft 20 ft Concrete Gi Flow
[Monitoring ❑Recov ft ft
ml'
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.. VEL PACK
❑Aquifer Storage and Recovery ❑Salimty Barrier Barri FROM tt TO MATERIAL EMPLACEMMAMHOD
ft
❑Aquifer Test ❑Stotmwater Drainage ft
❑Experimental Technology ❑Subsidence Control p
ZR DRIt;LLII�1�ZOfi attar ad8itoe�
❑Geothermal(Closed Loop) ❑Traur FROM TO DESt 1TON color hardens,sdl/roclt lype,grMn stle,etc
OGeothermal(HeatingCooling Return) ❑Other(explain under 421 Remarks) Q ft ft 1
�3 ZS 2_5ftsa 4.Date WcH(s)Completed: Well IU# ft' A
&L Well Location: ��C
M.4f, ft M
Faci(ityl/Owns Name Facility ID#(ifapplicable) - - — ^-
Physical Address,City,and 'p a r
. 2L REMARKS I �
Z2 4Z�
County Parcel Identification No.(PIN)
!J U
5b.Latitude and Longitude in degrees/minutedseconds or decimal degrees: 22 Certidication:
(ifwell field,one laMong is sufficient)
3 S°3lv l/6 f�77�0'� N !M I5q, /Aa" " W
Signature of sea Well Co for Date
6.Is(are)the well(s): rEIPCtmanent or ❑Temporary By yipsog dus fom;I lwmby cemfy,drat the wefl(s)-was(were)consirmled in accords=
� with 15ANCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standmvds and that a
7.Is this a repair to an existing well: ❑Yes or 131 copy of this record has been pmvi&d to the well owner.
1f this is a repair,fill out lvtown well conmicdonWwwation and explain the nahi a ofthe
repair wider#21 rmarks section or on the back of d=fmm 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.
Formu aple trgecJtm onion-watersepply wells ONLY with the same cortsriuoYian,you can
submwarefmm SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: A OJ (R,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tV kVkrad(exmnple-3@200'and2@!00) construction to the followvlg:
10.Static water level below top of casing: so A) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Marl Service Center,Raleigh,NC 27699-1617
1 L Borehole diameter. :w 010 24b"For Iniedion Wens: 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
i..Well construction cable, method-pusk Rotary construction to the fullowiag:
(i.e,auger,rotary,cable,direct push,etc,) '
Division of Water Quality,Underground Injectiot Control Pavgram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpin) 30 Method of test. Blowing-Rig 24c.For Water Sunnly&Injection Wells: to addition to sending the.form to
the address(es) above, also submit one copy of this form within 30 days of
136 Disinfection type: Chlorine the
�� OZ. completion of well construction to the!county health department of the county
where constructed-
Form M-1 - North Carolina Department of Envimmnent and Natural Resources-Division of Water Quality Revised Jan.2013