GW1-2023-02053_Well Construction - GW1_20230303

WELL UU1 KIRUC TION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts 14.WATER'ZONES
FROM I TO DESCRIP ION
Well Contractor Name ft D ft
NCWC 2028-A ft M
NC Well Contractor Certification Number IS.OUTEACASING or.multi-casedlwells OR LINER:d ble
FROM TO DIAMETER Tt0['KNESc I MATERIAL
Ferguson's Well and Pump, LLC 0ft ft f -5 in- ` r
Company Name 16.INNER G OR TUBING. closed-lou
R z U Z 2 . G a yaR FROM TO DIAM TF.R THICKNF.S MATERIAL
2.Well Construction Permit#: ft fk in.
List all applicable well construction pemrlis(r.e.County,State,Yarimrce,etc.)
ft ft in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT s= I THICKNESS MATERLAT-
❑Agricultural ❑MuuicipaUPublic ft ft in
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft in
❑Industrial/Commercial ❑Residential Water Supply-(sbared) 1&GROAT _
FROM TO MATERIAL EMPLACENEM111E1'I;OD AMOUNT
Non-Water a ,S�fpply Well: 0
❑ aon ft ConcreteGravity-Flow
ft Gravi Flow
❑Monitoring ❑Recovery ft ft
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK e
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLAclrrrnLLzTIOD
ft ft
❑Aquifer Test ❑Stormwater Drainage
ft
❑Experimental Technology ❑Subsidence Control ft a
2&DRILLING LOCH:atbWh addiiioaal sluxtsff
❑Geuthertnal(Clused Luup) ❑Tracer FROM I TO DFSCIUMON color hardness,soitlroctt gpe,gran 92 etc
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft S .ft
to ft
4.Date Well 10s)Completed: Well �� ft O ft
Sa.WeII Location:
� A-�I it � ft t'
`V+r I L 1'S r/�t/�Qn�!/% f! l P r ft ft
FacilitylOwnerName �1 Facility IN(if applicable) ft ft
43 -6A14- f4ar—.L-s .r•.e Le1re-sfP./PS718 ft f t
Physical Address,City,and Zip 2L REMARKS j'�a
^ uM ry„ C `
-� �7AbwF5rac* Ma, ,j � ^�
County Panel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22
(if well field,one lavlong is sufficient)
Certification:
-l 5'/S,/mi I N A-°z/s' rr�?u 73$ t WAILat
rgnature of crtificd Well Can ter Da
6.Is(afro)dfe well(s): Zernrancnt or ❑Temporary By signingthis form,I hereby certify that the weU(s)leas(were)constructed in accordance
With 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Stmrdords and that a
7.Is this a repair to an existing well: ❑Yes or IaiVu copy of this record has been provi&d to the well owner.
If this is a repair,fdl out!Drown well construction h fornation and explaw the nature of the
repair under#21 remarks section or on the back of ihisfomh 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.
FornuUtple byection or non-water supply wells Ohl Y with the sane construdion,you can
submit oneform SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 3[ S (fL) 24a. For All Wells: Submit this form within 30 days of completion,of well
For multiple wells list all depths if different(example-3@a 200''annd 2@100') construction to the following:
10.Static water level below top 7 of casing: 0 (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (in.) 24b.For Tnieetion Webs: 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(i.e.
cable, method: Rotary construction to the folloving:
(i.e,auger,rotary,cable,direct push,etc.)
Dh ision of Water Quality,Underground InjectioLiControl Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
132.Yield(gpm) O Method of test: Blowing-Rig 24c.For Water Supply&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: 50 QZ, completion of well construction to the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013