GW1--04283_Well Construction - GW1_20230626

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information:
BobbyAl Potts - 14..WATEkZONFS_• -_..... .
. FROM TO .- DESCRIPTION
Well Contractor Name • ft. / ft
NCWC 2028-A ft (JC19 ft }
NC Well Contractor Certification Number • • 15.OUTER CASING(for nultiessedwails)OR LINER ofau ble)
Ferguson's Well and Pump, LLC °0M f� T° Die„ft- -6,,AS' hi. 2� MATERIAL
Company Name 16.1NNE R GORTURING'(gedshermale16` ) � ���Z�
,e• • +—� 1 p FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: . Di • I i 7 a p, ft ft. m.
List all applicable well construction permits(Le.County,Stale,Variance,etc.). '
ft ft in •
3.Well Use(check well use): 117 SCREEN • -
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑ ipal/Public ft ft in
OGeothermal(Heating/Cooling Supply) Kesidential Water Supply(single) ft ft irr
❑Industria]lCommercial ❑Residential Water Supply(shared) 18 tRtOiJT:. • - .
FROM TO MATERIAL . EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft 20 ft Concrete Gravity-Flow
Non-Water Supply Well: ft R .e
❑Monitoring ❑Recovery
Injection Well: ft ft ,
DAquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK tif. Me) .. -
❑Atplifer Storage and Recovery ❑Salinity Barrier ft. ft:FROM TO MATERIAL- . EMPLACEMENT METHOD
OAquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control t
20:DRILLING LOG(itttdi additional sheds ifnecessary)
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION(color,hardness,soNrodt type,grain sire,etc.)
❑Geothermal(Heating/Cooling Return) 2g DOther(explain under#21 Remarks) ® ft 9,5 .ft ,A /,,,, w y�
4.Date Well(s)Completed:��, a 3-Well ID# •
�,�t +S� ft ( � G(%S/` /an
S- ft '6 ft ` ' r(.G r
Sa.Well Location: /�/ J
.W /- 7(Y ft 6 g2©ft (}•G�GtG��/ C
( - `ctt.L M l I tt7(.tf ft ft
Facility/Owner Name Facility,l ID#(if applicable) ft ft �
r y� t�(f `.) V� ` rci, ,.( rat 7S 3i. nI'--�-,u--a, r,g
l�-7 Yl at fir-)U U� eaJ t/ct It1 c ft. ft 'e i;�. -.r�L..b tl Physical Address,City,and Zip . •
• r/v�ua� i Cm • 9 '7ay-08 - �3 a 2LREMARK5 JUN 3 G 2023
County Parcel Identification No.(PIN)
6nfr.rraj-on ?rcCmq.:-e,g Una
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: . G1�7;i1r TLY+r
(if well field,one lat/long is sufficient)
/gy
r
,1Y-C(S'D0p P orn.a- N 5.�>ve935 t o A)y77� I w A
� Signature of 'fled Well Contractor Da� 3 23
6.Is(are)the well(s): BFermanent or ❑Temporary By,,ice this form,I hereby cerfijy that the well(s)-was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 211 o copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of thisfomr. 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 iryection or non-water supply wells ONLY with the sane construction,you can
submit one form. Q!� SUBMITTAL INSTUCTIONS
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9.Total well depth below land surface: (2 50 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths((different(example-3@200'and2@100') construction to the following:
10.Static water level below top of casing: 60 (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 Injection 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 Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 27(0 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
136 Disinfection type: Chlorine Amount: �e oz. completion of well construction to 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 .