GW1-2023-02046_Well Construction - GW1_20230303

KU U 11VA KEUk)M" For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts z4.w�mE>
PROM TO IrESCRnMON
Well Contractor Name & ft
NCWC 2028-A ft 14ilo ft
NC Well Contractor Certification Number 15-OUTERCASING atrum8.�.vrells ORLUMMM f bb:
FROM TO DIAMETER MUCE14M MATERrAL
Ferguson's Well and Pump, LLC 5 ft. f, I/,,.As in, CS
Company Name 16.INNER R .G OR G:' rimed
FROM I TO I D TH e7mmS I MATERIAL
2.Well Construction Permit#: ft ;n
List all applicable well construction perncts(te.Courtly,State,Varimrce,etc).
ft ft in
3.Well Use(check well use): 17 SCRft.
Water Supply Well: FROM TO DIAMETER SLOT SIZE I THICENFM I MATMLAL
❑Agricultural ❑Municipal/Public ft ft .ia
❑Geothermal(Heating/Cooling Supply) 2Kesidential Water Supply(single) ft. ft bL
❑Industrial/Commercial ❑Residential Water Supply(shared) 18:.QtOUT.
FROM To MATERIAL 13M ACEMEliT?JMOD�AMOUNT
Non-Water Supply Well: 0 �-
❑ a r` 20 f` Concrete Gravity-Flow
Flow
❑Monitoring ❑Recovery
rt. ft
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19..SAND/GMVEL PACK
❑Aquifer Storage and Recovery ❑Salimty Barrier ft PROM fG
TO MATERIAL IIeLACEMM1%MMOD
❑Aquifer Test ❑Stomtwater Drainage R ft
❑Experimental Technology ❑Subsidence Control r'
20�DRII.IsIING LOG 'adiblG*g abeels
❑mutheamal(Closed Loup) ❑Tracts FROM To DES(Rip1TUN color hardn wturock stle,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 0 ft ft C(4y .
4.Date Wcil(s)Completed: 3 Well ID# 7S ft. Q ft
Sa.Well Location: f O O 0
T�:a ft. ft
Facility/Owner Name Facility MN(if applicable)
14 .Clncv r�-t Tonr�il L-EC�S�e r ,�8?� f` _ .. j"
ft. ft
c �
Physical Address,City and Zip 2L RFM Rli 8 A 2 '2
County Parcel IdentifieationNo.(PIN) "
fib.Latitude and Longitude in degrees/minutes/seronds or decimal degrees: 0"u'lLM
(if well field,one Wong is sufficient) 22.Certification:
Sigaamre of . ed Co for Da
6.Is(are)the well(s): ermanent or ❑Tempormy By,rignirg dis forrrc I hereby cer*dun the weA(s)`was(were)consinacted in accordance
with 15ANCAC 02C.0100 or 15ANCAC 02C.0200 Ruch Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or a copy of tits record has been promMio due well owner.
If this is a repair,full out brown well construction bfmmation and explain the nm'we ofthe
repair wader#21 rmxmb;section or on dw back of d=fomr. 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 wcls constructed: construction details. You may also attach additional pages if necessary.
Forrmdnple iryectton or non-water supply wells ONLY with the same catshucvon,you can
submit oneforn SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 'r S (fk) 24a. For All Wells: Submit this form within 30 days of completion of well
Farmdaple wells list all depths ifd fferent(example-3V000'and 2Q100� oonsttuction to the following:
10.Static water level below top of casing: 60 1 A) Division of Water Quality,Information Processing Unit,
Ifwater level is above casing use"+" 1617 Marl Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. ;w _ (im) 24b.For Iniection Welly: 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 wen construction method: ry construction to the folloming:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injectiolt Control Prpgr'am,
FOR WATER SUPPLY WELLS ONLY: M%Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method oftest. Blowing-Rig 24e.For water Sunrdv&Iniedion Wells: In 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
i
Form OW-1 - North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013