GW1--04291_Well Construction - GW1_20230626

W LLL CUNS fI(U(;IlON RECORD • For Internal Use ONLY:
This form can be used for single or multiple wellss
1.Well Contractor Information:
Bobby W. Potts - 14.WATEI :
FROM TO . I' DESCRIPTION
Well Contractor Name • • g, 3D0 ft
NCWC 2028-A ft �5��? ft
NC Well Contractor Certification Number IS.OUT+ACII PIG(fotmnlfi ed.wens)ORLINER fd-��)
FROM TO DIAMETER THICKNESS MATERIAL
Ferguson's Well and Pump, LLC 0 f` RS & e,,Rs ,/'' 3$e c/
Company Name 16.INNER CASING OR-TUB NG,(g; mad dosed-loop)
r p FROM TO DIAMETER THICKNESS MATERIAL
2 Well Construction Permit#: Ot (a�( v a. 6(p 1 ft. . . ft in.
List all applicable well construction pernuts(Le.County,State,Variance,etc.). ,
ft. ft is
3.Well Use(check well use): 17.SCREEN
Water Supply Well: • FROM TO DIAMETER SLOT SIZE THICKNESS MATEERIAI,
❑Agricultural ❑Municipal/Public
ft. ft is
❑Geothermal(Heating/Cooling Supply) :R�esidential Water Supply(single) °1 •
❑Industrial/Commercial BKesidential Water Supply(shared) i&.(iMUT.. . .. .
•
❑Irrigation
FROM TO MATERIAL • EMPLACEMFNTMETHOD&AMOUNT
Non-Water Supply Well: 0 , ft 20 ft Concrete Gravity-Flow
❑Monitoring ORecovery
ft ft
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 'it.SelND/l lVEL'PACK(ifinalirable) •
❑Aquifer Storage and Recovery OSalinity Barrier PROM TO MATERIAL EMPLACEMENT METHOD
ft ft:
OAquifer Test OStormwater Drainage
❑Experimental Technology OSubsidence Control if,
OGeuthetmal(Closed Loop) OTracar ' 2aDRILLINGLOG(nttat sheets ary) ..•
FROM TO DESCEIP FIoN(color,hardness,soNroclt tw a,�she,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) C? ft /D It Clay
�./ S(/� �Sfea.c..
4.Date Well(s)Completed: �/ y A 3 Well IDS /�� ft / ft as.Well Location: A/ ft V d f-J7C
Ak�Wil� 'A rel.. 2 f ?dSft . 1 '(r�/lTe
Facility/Owner Name Facility ID#(if applicable) ft ft
W TJ n.� ��=k.) tt ,u y;Ykldrt .�S 7 ft ft ' r'G%�.,'4..,[t...s v I.
Physical Address,City,and Zip
21.REMARES Zl C3
•�Re,pArcn n �tz{a f�bSf (p JL
Parcel Identification No.(PIN)' ?rC. _r`Y J l;r
Sb.Latitude and Longitude in degrees/minutes/seconds1ri3i W:'`- •���s
ngi or decimal degrees: 22.Certification: _'�=� .�
(if well field,one lat/long is sufficient)
,3S°ly t2015/$griN $Ac'0.S'f5-04 ' ''/8g w
S of ' ed n e t-"..'5(V-7°31----
6.Is(are)the well(s): laPermanent or ❑Temporary
By sib this I hereby certify that the weA(spwas(were)constructed in accordance
with 15A NCAC 02C.0100 or ISANCAC 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 cortrtruclion bformalron and explain the nature of the
repair wider#21 remarks section or on the back of thisform. 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.
Formultiple iryection or non-water supply wells ONLY with the same conslruction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 6S (g,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths((different(example-3(200'and 2@100') construction to the following:
10.Static water level below top of casing: (10 (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._ _ 4 (in.) . 24b_For Inieetinu 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 Injectidjl Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) t/01\ Method of test Blowing-Rig 24e.For Water Supply&Iniection:Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
-13b.Disinfection type: Chlorine Amount• /_ 2 OZ. completion of well construction to the county health department of the county
�G Q� where constructed _ 1 I
Form OW-1 • North Carolina Department of Environment and Natural Resources—Division of Water Quality • Revised Jan.2013