GW1-2023-02164_Well Construction - GW1_20230306

W LLL l:U1NS'1 RU Ul'IOIN RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: -
14.Bobby W. Potts FROM R TONFs DESCRIPTION
Well Contractor Name ft 3 t11 J)ft ,
NCWC 2028-A It. / v ft
NC Well Contractor Certification Number 15:OUTER CASING(for multi casod.wells)OR LINER Of apgAsable)
. FROM TO DIAMETER THICKNESS MATERIAL
Ferguson's Well and Pump, LLC r3-ft 6, ft (r/ ,n //�J r e2[`
Company Name . . 16.INNER I'GORTBING: dosedr-I �UrS�K
Weil COIIStrIIction Permit# FROM ft TO ftDIAMETER in. THICKNESS MATERIAL
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( II 611 Tara
List all applicable well construction permits(i.e.County,Slate,'Variance,etc.)
ft ft in.
3.Well Use(check well use): 17.5CREEN
Water Supply Weil: , FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural ❑Muunicipal/Public ft ft m
❑
❑Geothermal(Heating/Cooling Supply) Earl sidential Water Supply(single) ft ft m.
❑Industrial/Commercial ❑Residential Water Supply(shared) •1&.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation
Non-Water Supply Well: 0 ft 20 ft Concrete Gravity-Flow®
ft ft
OMonitoring ❑Recovery
Injection Well: ft. ft
❑Aquifer Recharge 0 Groundwater Remediation 19.SAND/GItAVEL PACK(rf applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier f. ft: .. . .
❑Aquifer Test ❑Stomrwater Drainage ft. ft
❑Experimental Technology 0 Subsidence Control . t,
20.DRILLING LOG(attach additiboal sheets if>ecessary)
❑Geothermal(Closed Loup) OTracer FROM To DESCRIPTION(color,hardness,soil/rock type,orate stxe,etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 50 .ft Clay
4.Date Well(s)Completed:/0�/ 22 Well ID# sort ft (�OG ft 'a1:5411.. .Sa.W l �V f �vft
/ o( l -
Well Location:
h:2iIACwna-TItr hi m .1: 6 ft d�, ft �u�rr/c — ,
Facility/Owner Name Facility ID#(if applicable) rTh
1d�1yy ,{ ft. ft ..•,. `:1.-.ts:.,.i i� ;-
Physicaldtlreg C C.11'3O l/Q L//..-- �1D tkenJ//�h(d 1 I(-g8.79� ft ft MAR 07� .3�
City, P 2L REMARKS
14enclo(Sor a17? 1Lf 34:JR _: P_".;.._.:: ;n:i
County Parcel Identification No.(PIN) 1 r•�+ .-;c '
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
3S aa( IA 00A /IN 7.L°A7 '/e(i 571b r w' lr //A,Zl
/ Si o erti5 ell ntrac r Date
6.Is(are)the well(s): imanent or ❑Temporary
By signing this form,I hereby certify that the well(s)-was(were)constructed in acconlmrce
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well ConshvctionStandards and that a
7.Is this a repair to an existing well: ❑Yes or o copy of this record has been proviekd to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair corder#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
S.Number of wells constructed: / construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit are form. SUBMITTAL INSTUCTIONS
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9.Total well depth below land surface: 4/A c (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tf "neat(example-3@,2 0'and 2@100') construction to the following:
10.Static water level below top of casing: O0 (f{,) 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. . _ 4 (in.) 24b.For Infection 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 Injecting Control Pwgram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
Blowing-Rig 24c.For Water Supply&Injection Wells: In addition to sending Yield(gpm) Method of test: g g the form to
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the address(es) above, also submit! one copy of this form within 30 days of
Chlorine SD oZ. completion of well construction toj the county health department of the county
-13b.Disinfection type: Amount: where constructed
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Form CAW-1 • North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013