GW1--04301_Well Construction - GW1_20230626

wLI L(,V11101KUL.1IVAA1 KELAJKIU For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
BobbyW. Potts • 14:WATERzONFS: _. I
. PROM TO . , DESCRIPTION
Well Contractor Name ypD I - .
NCWC 2028-A - 'it. ft . ' •
NC Well Contuetor Certification Number , , 15.OUTER CASE%(for nnitivased wells)ORLU ER(ifapure:able)
FROM TO DIAMETER THICKNESS MATERIAL
Ferguson's Well and Pump, LLC d f. -33 ft. 6t AS in. 2/7/4,25 PUcSQg,2/
Company Name - . 16 INNER CASING OR TUBING(ggotbermal dosed-lobo)
na 1 /�!`/ ' FROM TO DI1MI;TER THICKNESS MATERIAL
L Well Construction Permit it: d` —. �JIJ`•l ft ft in
List all applicable well construction permits(I.e.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 ❑ Public ft • ft. in.
❑Geothermal(Heating/Cooling Supply) esiater Supply(single) ft ft in ,,
❑lndustrial/Commercial ❑Residential Water Supply(shared) 1L.GROUT.. . - -
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft ft-
Non-Water Supply Well: ft 20 Concrete Gravity-Flow
ft
OMonitoring ❑Recovery
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 19..SAND/GltAVEL'PACK1f. bie) . •
❑Aquifer Storage and Recovery . ❑Salinity Barrier PROM TO MATERIAL ft ft: _ . EMPLACEMENT METHOD .
❑Aquifer Test ❑Stormwater Drainage ft ft .
❑Experimental Technology ❑Subsidence Control e
.28:-DRILLIN LOG(ittadi'addlfeoeal sheetsifi rA
['Geothermal(Closed Loop) ❑Tracer PROM TO DESCRIPTION(color,hardness,soil/rock type,grain Site,etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) C)ft /J -ft /r in/
_ 22ft 2,5 ft S f�aC
4.Date Well(s)Completed: / 7 Well 1D#
7 ft ft �-,te /l e C/JC_
oa Well Location: 3 3 R 70 S fa (!_4R'w/17 C
• C&1 prt CAr4t-r- ft. ft
FacilitylOwner Name Facility ID#(if applicable) ft. ft
1(ia L'-t it + U tal l e.3-Q? Le I'L er ,-9 ci ' ft ft v w...r I\ �.d .:
Physical Address,City,and Zip 21.REMARKS
.1?)tdrlrl00"/6.e. - - -7 el►L( I Ci 0 01 0000 J"tiii i ? 2023
County ' Parcel Identification No.(PIN)
tn{,u-m-,541 ii Prod-r'rtr'f.i Unis
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: DV '3OG
(if well field,one lat/long is sufficient) �/Q/f�/ •
3 563 ��($f (//4 frN 72°1!3%pt / b rr w , -
Signature of C " eel Well Contracto 4/1412k3-
6.Is(are)the well(s): Permanent or 0 Temporary
BY signing this fore,I hereby certify that the weA(s)•ens(were)constructed in accordance
with ISA NCAC 02C.0I00 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing will: DYes or Et 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 nohow 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
S.Number of wells constructed: / construction details. You may also attach additional pages if necessary.
For multiple ttgection or non-water supply wells ONLY with the saute construction,you can
submit one form SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 70s (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdrfJeremt(example-3@20000'and 2@100') construction to the following:
10.Static water level below top of casing: U (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 :f_ _ 6 On-) 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
1L Well construction method: rY construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injectiop Control Prpgram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
•
13a.Yield(Spun) A Method of test: Blowing-Rig 24c.For Water Sunpl,&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 6 OZ• completion of well construction to the county health department of the county ,
where constructed.
I
Form 0W-1 - North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013
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