GW1--06328_Well Construction - GW1_20230927

W 11+LL l.Ulra 1 nu to lUi' MECUM ) • For Internal Use ONLY: • I '
This form can be used for single or multiple wells
1.Well Continctor Information:
Bobb .W. Potts . . . •14.WATERZONES • I I •
Y . FROM • TO , DESCRIPTION
' Well Contractor Name ft 1,ftd ft
. NCWC 2028A ft ft. M . •
• NC Well Contractor Certification Number. 1S.OUTER CASING(for multi cased wells)OR LINER(if biz)
FROM ' TO • DIAMETER I THICKNESS MATERIAL
Ferguson's.Well and Pump, LLC . (9 ft. /i)<• ,,A5 "` 2/, ,/AS Pt/ c',42/
Company Name . • • . 16.INNER CASING OR G.(tteothermal dmed4oup) .
PROM TO DLANIETFR; THICKNESS•. MATERIAL
2.Well Construction Perinit#:. ZO?3 -.00 li-1 0 ft ft - I •hi .
List all applicable well constriction permits(ie.Comity,Stale,Varimrce etc.) '
ft ft I• in
. 3.Well Use(check well use): 17.SCREEN '
Water Supply Well: . . •FROM .' To DIAMETER SLOT SIZE THICKNESS MATERIAL-
•❑Agricultural ❑ blic ft ft in 1 . • • .
❑Geothermal(Heating/Cooling Supply) cstdential Water Supply(single) ft ft a'
❑Industrial/Commeicial ❑Residential Water Supply(shared) • 18.GROUT . •- -
•
FROM . TO .MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irigatite . . 0 ft 20 • .ft Concrete . Gravity-Flow .
Non water Supply well: • ft ft.
❑Monitoring ❑Recovery
Injection Well: . • . . ft. - ft
. :❑Aquifer.Recharge . , • . . °Groundwater Remediation 19.SAND/GRAVEL PACK Of applicable)
FROM • TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery• - -❑Salinity Barrier ft -
• ❑Aquifer Test ❑Stormwater Drainage
['Experimental Technology OSubsidence Control ft ' .. >'
20.DRILLING LOG(attach additiimtal sheets if necanar9)
❑Geothermal(Closed Loup) ❑Tracer • •FROM . TO . DESCI f'TION color hardness,solUrodt type,;trims she,etc)
5
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) :0 ft .7 . .ft • : C` a y' .• •
4.Date Well(s)Completed: 53-7 2 3_Well ID# �� ft TO' it i s'a����! c}(�e
5a well Location: �� ft /aA ft I; e itoc�fc
/0;7•f 7iSf' '6tvwi74e.
(C,VWr, An.a-cine i l . ft ft
.Facility/Owner Name : Facility lD#(if applicable)
•
40 (Zeta •POE* •d- r 4i' i1 i 6 tL., 'l3 0 n. . .
. ft ° ti-• °n
Physical Address,City,And Zip • '' a
ZL REMARILS I' s t P 7 71123
—Sur. t;aivl& cgs;$S a 7 3 3Dg -
County . • Parcel ldentifcationNo.(PIN) tiltorif. i Pl
..,.�.:.' l;r,
S-b.Latitude and Longitude in degrees/nririutes/seconds or decimal degrees: 22.Certification: .
(if well Seld,one hit/long is sufficient) !• •
..�s° 0-'v16r4l��'g/N 0 ` 2.SID el;�g.ZY 'or w �� !/t� %1,�
Signature of Ccrtiffed Well Contractor 1, . .- D
6.Is(are)the well(s):,QPCrmaneat or OTemporaly signing this Iwell(s) (were)constructed in accordance•
iSy. grning. form I hereby certify dra�the was
• with ISA NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that!:
7.Is this a repair to an existing well: • DYes or Gil< copy of this record has been proviekdto�well owner.
If this is a repair,fill out known well construction vfon nation and explain the nohow of the .
repair under#21 remarks section or on the back ofthisfonn. 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: I construction details. You may also attach additional pages if necessary.
Fornadtiple injection or ruin-water sip*wells ONLY with the sane construction,you can I '
submit one form. SUBMITTAL INSTUCTIONS .
9.Total well depth below land surface: 7�.'- • (ft.) 24a. For All Wells:. Submit this,form within 30 days Of completion of well
For multiple wells list all depths(Id eret(example-3@200'aid 2Q100') • construction to the following: . •
.
•• 10.Static water level below top of casing: . 9) . . . . .(ft) Division of Water Quality,Information Processing Unit, .
Ifwaterlevelis above casing,use"+" 1617 Mail Service Center,Raleigh,NC27699.1617
11.Borehole diameter. .�•` (in.) 24b. For Insertion Wells: In add f tion to sending the form to the address in 24a
Rota above, also submit a copy of thus form within 30 days of completion of well
12.Well construction method: Rotary construction to the following:
(i.e.auger,rotary,.cable,direct push,etc.) . - - -
Division of Water Quality,Underground Injectionf Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636 .
• 13a.Yield.(gpni) d - Method of test Blowing-Rig 24c.For Water Supply&Iniecti Wells: In addition to sending the form to •
the addresses) above;also submit one copy of this form within 30 days of
13b Dismfectioa type: Chlorine Amount: oZ, completion of well construction to I the county health-department of the county•
where constructed.
Form O W-I • North Carolina DepaRment of Environment and Natural Resources—Division of Water Quality Revised Jan.2013 •