GW1--04320_Well Construction - GW1_20230626

W ,1.�LL WiltN.11KU1;11U!N Hl+',CUKD For Internal Use ONLY:
•
This form can be used for single or multiple wells ,
1.Well Contractor Information: •
BobbyW. Potts -- 14..WATERZZOJES1- -..;
PROM TO • , DESCRLPITON
Well Contractor Name ft. .2/0ft -
NCWC 2028-A =-` : ft. ft. • j I .
NC Well Contractor Certification Number • • , • IS.OUIER A 1NG(for nralerestied wells)ORIMER(if ap able)
FROM TO DIAMETER THICKNESS MATERIAL•Ferguson's Well and Pump, LLC p ft' / td ft 40. /6,w A spn 2/
Company Name 16.INNER G OR TUBING: dosed-lotrp).
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: . 2'0Z-Z - 60 G.3 a ft. ft hi.
List all applicable well construction permits(Le.County,State,Variance,etc.).
R. ft in. . i
3.Well Use(check well use): - 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SEE THICKNESS MATERIAL
ft ' ft in.
❑?.grictilttrral Kf_fi.r ieipal/Pnblic
❑Geothermal.(Heating/Cooling Supply) Residential Water Supply(single) ft ft °6 •
,
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18..(RLO[7T:
FROM TO MATERIAL * EMPLACIIuIL+N'f ML'fHOD&AMOUNT
❑Imgation
Non-Water fiupply Well: s 0 , ft. 20 ft Concrete Gravity-Flow
ft. ft
❑Monitoring ❑Recovery
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 19..SAND/GAAVEL PACK(if ble)
❑Aquifer Storage and Recovery. ❑Salim Barrier PROM TO MATERIAL . EMPLACEMENT METHOD
�' ft. ft:
❑Aquifer Test ❑Stormwater Drainage ft ft. •
❑Experimental Technology ❑Subsidence Control
20:DRILL NG LOtr'.(attach adiltiinal sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer . PROM To DESCRU'TON odor,hardness,sdltroctt type,ftsin the,etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. y S ft c/6 y` .
4.Date Well(s)Completed:5; A 3 Well ID# $`r ft lad ft s p or ,�(„r
�
5a Well Location:: /Ov R �SD ft- AE' tOC /-
ol�n c L.i'_C 10 ft. 3cS ft . GP�t,OrYe
rtr ft. ft L_.F 1• 'i e C""•:
Facility/Owner Name Facility ID#(if applicable) •L. 1 �° 1—'' :
ft f
I S7(1rI Ore t1l_164tO Aiiitr. ,PiQ%0�-
ft ft. sUIV ,,j . 2O2J
Physical Addrafs,City,and Zip •
2LREMARiLS Iilf.n :'.;:n Pr..rc-Tr..a3 Un
P)u-11COnlb._ - g1, iga.>t , a3 (P Dtit� OS
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degreeslminutes/seconds or decimal degrees: 22.Certification: •
(if well field,one Iatilong is sufficient) .
35 Dar �lrSSin 5j,�39r. '3 7.52 qg t • w 063-
&4Wd&'J14
6.Is(are)the well(s): ermanent or ❑Temporary By sigitin8 this form,I hereby ceryh,that the well(s)`was(were)constructed in accordance
with I5ANCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well ❑Yes or E3Plo copy of this record has been provtdbd 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 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
8.Number of wells constructed: ( construction details. You may also attach additional pages if necessary. •
For multiple tr#ection or non-water supply wells O1VLPwith the same construction you can -
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 3 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Fornatlkple wells list all depths ifd ifferent(example-3 00'wzd2 ,100') construction to the following:
10.Static water level below top of casing: ,7() ( ) Division of Water Quality,Information Processing Unit,
If water level is above'casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
1L Borehole diameter. •'._ _ () (in.) 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: ty construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injecting:Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield m Blowing-Rig 24c.For Water Sunpty&Injection'Wells: In addition to sendingthe form to
(gp ) 3© Method of test: g g
the address(es) above, also submit 1one copy of this form within 30 days of
I136 on type: Chlorine Ammmt 5 Q DZ, completion of well construction to;the county health department of the county
V where constructed. _ ,
Form OW-I - North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013