GW1--04314_Well Construction - GW1_20230626

TV£JLL 1.-PINO 11%U1.11V1' EA-UALJ I For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
BobbyW. Potts 14..WATEIf-z�ONFS_: .. .. ,
y FROM ,TO 7 , DESCRIPTION
Well Contractor Name ..• ft /Qn ft
NCWC 2028-A -ft ( 2.0 ft . .
NC Well Contractor Certification Number , • 15:OUTER.CASING(for mmfi cased.i[dls)ORLINER(if apphaahte)
FROM TO DIAMETER I THICKNESS MATERIAL
Ferguson's Well and Pump, LLC ' 0 rr. / /r '�' Z/ M/c5N)/
Company Name 16.INNER CA G OR vG,(itecdsermal -loop)
,e' FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: . 01 b a a - .60579' fc ft in.
List all applicable well construction permits(Le.County,State,Variance,etc.), ft. ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM To DIAMETER SLOT SIZE TRICKINESS MATERIAL
ft • ft in.
❑Agricultural eneipallpublic
OGeothermal(Heating/Cooling Supply) esidential Water Supply(single) ftit is ,
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.t ROCT., . -
FROM TO MATERIAL ' EMPLACEMFNTMETHOD&AMOUNT
❑lnigation 0 ft 20 ft' Concrete Gravity-Flow
Non-Water Supply Well: ft ft o
OMonitoring ❑Recovery
Injection Well: ft. ft
❑Aquifer Recharge 0 Groundwater Remediation 19..SAND/GAVEL PAC&.0f iicatde)
❑Aquifer Storage and Recovery ❑Salinity Barrier - FROM TO MATERIAL EMPLACEMENT METHOD
R fti
❑Aquifer Test ❑Stormwater Drainage ft. ft
:Experimental Technology ❑Subsidence Control t
?A DRILLING LOG('dadradi6iimil abaft if necessary)
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTT (color,hardness,soNrock type,gram sin,etc]
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft VS .ft /I(
01/2 s ft 60 ft ( rff .
4.Date Well(s)Completed:% Well ID#
ft.
5a Well Location: le vft. �i•e l'e r4c
4,6 ft vs-ft w,47 e-
-b,i In:. I<1J _�(o ft. ft _
Facility/Owner Namd Facility MO(if applicable) "''X -
//� 'w;.-':..r 4..:.a kr le-.y...4
Q.10 l_ltr- I S r')-)K-`.r.6 LeiIi-er rICOyt ft. 'ft. JUN `? . 2023
Physical Address,City,and Zip ..
IL REMARKS
t.try pm b c- O 7 9a i g l„o A a intuit+ c Pr H.r• .a.
County Parcel Identification No.(PIN) G1r"tt `�`
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one latAong is sufficient) ,
3 S dVf 5-(4 "7732 I I N Ir0k°37'.5,f1 OV2 t r W $6.2__
Si ofCeell Contracthr
6.b(are)the well(s): BPetmanent or :Temporary
By signing this fora,I hereby certify that the weU(spwas(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 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 known well construction information and explain the native of the
repair wider 4121 remarks section or on the back of this form. 23.Site diagram or additional well details:
8.Number of wells constructed: / You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
For multiple iryectian or non-water supply wells ONLY with the same construction,you can
submit one form SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: R Y.5
(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3@200'and 2 I00') construction to the following:
10.Static water level below top of casing: 20 (ft) Division of Water Quality,Information Processing Unit,
If water'emits casing,use"+" 16e/Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: _ 4) (m-) 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 Injectiolt Control Pnpgram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636 •
13a.Yield(gpm) t/5 Method of test Blowing-Rig 24c.For Water Sum*&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 © QZ, completion of well construction to the county health department of the county
where constructed.
Form C-W-1 • North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013