GW1--04149_Well Construction - GW1_20240717

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: _
Bobby W. Potts 14.WAS-ZOO
FROM TO • , DESCRIPTION
Well Contractor Name ft 3 ?4,ft .
NCWC 2028-A ft. ft.
NC Well Contractor Certification Number • 15.OUTER CASING(for mnlfi.eased wills)OR LINER(if - ,.-)
FROM TO HUMMER THICKNESS MATERIAL
Ferguson's Well and Pump, LLC h ft 3, - n ,a 15 ' , (R ,'?(cLl
'�u lER r[J�nv
Company Name 1 CASING OR G(geothermal dosed-loop)
.- FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: c2 CJ 1 —a(f (7 - ft. ft in.
List all applicable well construcilon pernets(i.e.County,State,Variance,etc.)
ft ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM To DIAMETER_SLO'T SIZE THICICNESS MATERIAL
❑Agricultural ❑Ivfunicipal/Public tt ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in
❑Industrial/Commercial ❑Residential Water Supply(chafed) 18.GROUT -
FROM TO MATK U L ' EMPLACEMENT METHOD&AMOUNT
❑Irrigation _ 0 ft 20 ft Concrete Gravity-Flow
Non-Water Supply Well: -
❑Monitoring ❑Recovery ft. ft .
•
Injection Well: ft ft.
:Aquifer Recharge ❑Groundwater Rcmediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery 0 Salinity Barrier ft n
❑Aquifer Test 0 Stomrwater Drainage
—
ft ft
❑Experimental Technology 0 Subsidence Control ' r
20.DRILLING LOG(attach additiatral streets if necessary)
❑Geothermal(Closed Loup) ❑Tracer FROM TO DESCRIPTION(calor,hardness,soil/rock type,grain file,stcl
❑Geothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) () ft ft
04,Date Wells)Completed: Well DJ#
ft /5- ft S/if 1 g 1 I/�C
t z-s'ft
Se.Well Location: / /� Ca C/C
g cxct-�'►K"14,t Ltd ft.
Inn ft�. �j"a w�'�c
ft !/"`� ft
Facility/Owner Name Facility ED#(if applicable)
ft. ft
t1a lepp>,v 1-ktrinn (Tx rLt-J (potat #&Jill 7 ft ft `
q .
Physical Address,City,and Zip 2L REMARKS C U 74
'"--e..)Gine OM tie_ c1 7516704,4.Ser ►r�u..:�.. : �, -antra
County Parcel Identification No.(PIN) .•
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22 Certification:
0
3540 10( T7Y/r N sa°'3 A' 13i.SS6Y y W
Si of ' eel Well Con for 1c
•s27--,Ag.
6.Is(are)the well(s): ertuanent or ❑Tennporary By signing this fora;I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or QPIu copy of this record has been provided to the well owner.
If this is a repair,fill out brown well construction bfomtalion and explain the nature of the
repair under#21 mitosis 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 bgection or non-water supply wells ONLY with the same construction,you can
submit one fonn SUBMITTAL INSTUCTIONS
9.Total well depth below land surface OS (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if thf fereni(ermnple-3 00'and 2@100') construction to the following:
10.Static water level below top of casing: /D ' (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. Y (Q (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
Rota above, also submit a copy of this fort 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 Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Matz Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) /0 Method of test: Blowing-Rig 24c.For Water Supply&Injection Well: 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: 0 oz. completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013