GW1-2023-02148_Well Construction - GW1_20230306

W L�LL L.Ui I I'(U 1.IMP( MEAL ILMIN For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts FRO A T .- , D • lON
Well Contractor Name ft 3 c0 ft l
NCWC 2028-A rt mi ft
NC Well Contractor Certification Number -• Is otrraRcidoicout.m i wle ls)OR LIMA(if sa able)
PROM TO DIAMETER TWCENFSS MATERIAL
Ferguson's Well and Pump,.LLC . . 6 ft j L ;�,/i. :)° ,5J f2 ./
Company Name 16.INNER a, G ORG6ieedtermalderrad ).
k ^^ / n +, FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: PI b 1 /6 Eis - . R .- in.
List all applicable well construction permits(Le.County,Stale,Variance,etc.).
ft ft in. •
3.Well Use(check well use): 17.SCREEN • . .
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑ rpal/Public ft ft •
is
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft
❑Industrial/Commercial ❑Residential Water Supply(shared)' '1&GRMIT.. '- .
FROM TO MATERIAL " EMPLACEMENT METHOD 8 AMOUNT
❑h nation 0 ft 20 ft Concrete Gravity-Flow
Non-Water Supply Well:
ft. ft
OMonitoring ❑Recovery
Injection Well: ft ft
:Aquifer Recharge 0 Groundwater Remediation 19..SAND/ERiAVEL PACK fit ble) •
PROM TO MATERIAL F.1NPLACEMENTMEtHOD
❑Aquifer Storage and Recovery _ , ❑Salinity Barrier ft. -
DAquifer Test ❑Stomiwater Drainage ft. ft '
DExperimental Technology . OSubsidence Control .• r
213 DRILLING LOG6ittaekadtti heal shies ai ry) •
❑Geothermal(Closed Loup) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type,grain ate,etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) O ft /o .ft. %t/a y
•
4.Date Well(s)Completed: .r t Well ID# /,'a ft (7S ft 1 ([W11 /i we
7 / 7Sf S�'Y ft Jrrr(((13cItoe /e
5a Weil Location: • a dt SOS ft. db a W i (
Cf+rj 4artiin. ft. ft _ ;-.s,., L
Fatuity/Owner Name Facility tD#(if applicable) ft. ft ix •
f 3 Scar14 ri k-id)ge pip(41/', e.v763 ft. ft MAR C) 5 ?023
Physical Address,City,and Zip 2L REMARKS
MpiAl. "th - R7a'7i( .ct .,;.;::.1 pr:::2. .,0 l.11.:
County Parcel Identification No.(PIN) = "`I":'"t:
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.certification:
Of well field,one lat/long is sutlicient)
3 e yf '37, 779( ?A°37l /' t 2Sf h Pw -4� Z./ //f
Signature of C Well Contractor•
Da
6.Is(are)the well(s): rdPennanent or OTemporary Sy signing this font',I hereby certify that the well(s)`was(were)constructed in accordance
with 1SA NCAC 02C.0100 or I5ANCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or o copy of this record has been provided to the well owner.
If this is a repair,fill out brown well construction information and explain the nature of the • •
repair wider#21 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
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple irgectiai or non-water supply wells ONLY with the same consiruclion,you can
submit onefoem SUBMITTAL INSTUCTIONS
9.Total well depth below land surfacer • SO S (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths Vet event(example-3@200'and 2@,100') construction to the following:
10.Static water level below top of casing: 5 a (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 •,-i._ _ 6 (in.) 24b.For Nitration 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 Injectio$r Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service,Center,Raleigh,NC 27699-1636
1
13a.Yield(Spin) 3 Method of test: Blowing-Rig 24c.For Water S umly&Infection Wells: In addition to sending the.form to
the address(es) above, also subruit one copy of this form within 30 days of
13b Disinfection type: Chlorine Amount Q OZ. completion of well construction tot the county health department of the county
where constructed.
Form OW-1 • North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013