GW1-2023-02055_Well Construction - GW1_20230303

W.LLA.L KEUUKU For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts FROM4TER TO DESCRIPITON
Well Contractor Name & a 9 ft
NCWC 2028_A ft ! ft
NC Well Contractor Certification Number 15.OUTER CASING formnlfi-cssedwe& OR LINER d ble
FROM TO DIAMETER TIDCrrnruec MATERIAL
Ferguson's Well and Pump, LLC ( ft ,X5 in Z 1 GCS Z j
Company Name 16.INNER CASIENG OR TUBING: dused4ou
^ FROM TO I DIAMETER I THICKNESS I MATERIAL
2.Well Construction Permit ( 1 ft ft in
List all applicable well construction pernuts(i.e.County,Slate,�oriance,a c`i-
ft ft in.
3.Well Use(check well use): 17,SCREEN
Water Supply Well: FROM To I DIAMETER SLOT SIZE THICIINFSS MATERILAL
❑Agricultural ❑ ipal/Public ft ft m.
❑Geothermal(Heating/Cooling Supply) ential Water Supply(single) ft it in
❑Industrial/Commercial ❑Residential Water Supply(shared) "L GROUT -
FROM TO MATERIAL EMPLACEMENT METHOD a2 AMOUNT
❑hri ation 0 ft 20 ft- Concrete Gravity-Flow
Non-Water Supply Well:
ft ft
❑Monitoring ❑Recovery
Injection Well: M ft
❑Aquifer Recharge ❑Groundwater Remediation 19..SAND/GRAVEL PACK ff cahic
❑Aquifer Storage and Recovery ❑Salinity Bain FROM TO MATERIAL EMPLACEMENT h%'MODes ft
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control e
20:DRII.IIIdG LOG.attch additional abeels if
❑Geuthermal(Closed Loup) ❑Tracer FROM TO DES0tWn0N color,harda solUrock o d2 erne
❑Geothermal(Heating/CoolingReturn ❑Other(explain under#21 Remarks) ft 0 It
4.Date Well(s)Completed: �C Well ID# U ft �� it Se,'
I /J ft ft e A
Sa.Well Location: v ft �ft dt t.0
1
11 .owiC Olwsz.g:_ ft ft
FacilitylOivnerName 11 - Facility EX(ifaapplicable) ft ft _
SC; 27Vs4 Loan e - F-(P, fne O7•3 P. ft ft
Physical Address,C' ,and Zip
2L REMARKS _
urn .t 7 Sl., 17 1 �
25
County Parcel Identification No.(PIN)
5b.Latitude and Longitude to degrees/minutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient)
22.Certification:
3S®�.`f 'o��►Gtfl� r N far A6' �317-� tt W
'�Wj4v
Signature of fied Weli Con for
6.Is(are)the well(s): 2Permancnt or ❑Temporary By signing this form,I hereby certify that the wells)-was(were)constructed in accortivice
with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 04 copy of this record has been provided to the well owner.
If this is a repair,fill out known well constuction information and explaut the nature of the
repair under 921 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 or well
S.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple ogection or non-water supply wells ONLY with the same consirudiarc,you can
sub»ut one forme L' SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 7 (ft.) 24a. For All Wells: Submit this foam within 30 days,of completion of ivell
For multiple wells list all depths if different(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: - d (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 Iniection We11c: In addition to sending the form to the address in 24a
Rotary above, also submit a copy of this foam within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injectiot Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-16M
Blowing-Rigc. or Water upply&Iniection Wells: In addition to sending 13a.Yield(gpm) Method of test: 24 F Wt S ding the form to
the address(es) above, also submit one copy of this form within 30 days of
.13b.Disinfection type: Chlorine Amount: .50 OZ. completion of well construction to the county health department of the county
where constructed.
Form CW-1 North Carolina Department ofEnvironment and Natural Resources-Division of water Quality Revised Jan.2013