GW1--03008_Well Construction - GW1_20230303

yt'n .■.l.Vl\►71KU1.11V1r KLY:VKI For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts 14.w4T1�R
FROM TO iDFSCRWn014
Well Contractor Name ft _30 &'
NCWC 2028-A ..ft. rt
NC Well Contractor Certification Number OiITBRCASIl+IG mul6i edaidis ORLINER d bk
FROM TO DIAMETER IMCKNE4SS MATERIAL
Ferguson's Well and Pump, LLC 0 ft ft rX in
DAA
Company Name 16.WNER CAiSII11G OR TUBINGtgaudiern,21 dosed-lac
FROM TO D MUCF2VE8.S MATERIAL
L Well Construction Permit#: ' b -d U5o.(,O ft ft UL
List all applicable well covulruction pemdls(Le.Cororty,State,Varrmrce,
ft ft in
3.Well Use(check well use): 17.S13tfL
Water Supply Well: FROM TO DIAMETER SLOT SM TffiCKNM I MATERL4L
❑Agricultural ��£ �e ai/pttblic ft ft .is
❑Geothermal(Heating/Cooling Supply) esrdential Water Supply(single) ft ft in.
❑Industtial/Commercial ❑Residential Water Supply(shared) 18'.GROUT- "
FROM TO. MATERIAL EMPLACEMFNPMEMOD�AMOUNT
❑� �� f` 20 & Concrete Graft-Flow
Non-Water Supply well: �Y-
❑Monitoring ❑Recovery
f6 ft
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19..SAND/GMVEL PACK
❑Aquifer Storage and Recovery alinity Barrier FROM To MATEttIAI
❑S FI��LACEMPNrMETFIOD
fc it-
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control f t r
FD3t❑Geuthermal(Closed Loop) ❑Tracer TO DFSLTJIMo colmbardn sduroclt etcCGeothermal(Heatin oolin Return ❑Other( under#21 Remarks) zo
ft4.Date Wells)Completed: Well Il?# ftSa WeII Location: // ftLu hn 1�I�iF1 1 ft
Faci(i Name Facility lD#(ifapplicable) fL ft
Sa/LIG� ett^ 'Sktrr'I-xtyw Le( 16 2$71B h ft
_El 3`
--cal Address,City,and Zip MAR
� r
ZL REMARKS. 1 l J
-?91 q 4
County Parcel Identification
No.(PIN)
Sb.Latitude and Longitude in degreestrainutedseconds or decimal degrees: 22 Cerlffication:
(if well field,one Wong is sufficient)
%a Eva yN < �f2lPi _�w
S' true of CCU sea wen-UonbUtor DA
6.1s(are)the well(s): alr.manent or ❑Temporary By mgmyg dns fbn4 I fib,wry ,that the weA(sjwas(were)canvrwied m accormce
with 15ANCAC 02C.0100 or 15ANCAC 02C.0200 WeR Consirw im Standards and that a
7.Is this a repair to an existing well: ❑Yes or ❑No copy of dw record has been p?=&d to the well owner.
Ifthis is a repair,frJl oil brown well con4trt hon uformaiion and esplabt 8re nave ofthe
repair under#21 rentmfCs section or on the bark of th fomt 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 wcRs constructed: construction details. You may also attach additional pages if necessary.
Farmadtipk rryecum ornon-wtuersupply wells ONLYwith the same emutntdion,you can
subnut eneform SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: Y (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths Vf aVemd(exmnple-3@200'and 2@1M construction to the following:
Division of Water Quality,Information Processing Unit,
10.Static water level below top of casing: ( )
Ifwater level is above casing,use"+" 1617 Mao Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. _ (fto 24b.For Iniection Wens: 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,cablq direct push,etc.)
Division of Water l2dality,Underground Injectiop Control Pnygrato
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-16M
13a.Yidd(Spm) y Method of test: Blowing-Rig 24c.For Water Saonly&Iniection Wells: In addition to sending the farm to
the address(es) above, also submit one copy of this form within 30 days of
13b Disinfection type: Chlorine Amount �jI DZ, completion of well construction to the county health department of the county
6� where constructed-
Form CAW-1 - North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013
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