GW1--04151_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:
BobbyW. Potts 14.WATER-ZO)ES_
FROM TO • r DESCRIPTION
Well Contractor Name ft 30o ft -
NCWC 2028-A ft 37c ft
NC Well Contractor Certification Number 15.OUTER.CASING(for multi-casedi wills)OR LINER(If applicable)
FROM TO DIAMETER THICKNESS MATERIAL
Ferguson's Well and Pump, LLC 0 fr 7S iz
►2.5 2*/A.5" A f)/LZ1
Company Name 16.INNER G OR TUBING(fttutlsermal -loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Wea Construction Permit#: Z U L 3 - O 0 14 f CO ft ft M.
List all applicable well construction permits(t.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
ft ft in-
❑Agricultural ❑ ipal/Public
❑Geothermal Hea' olio Supply) esidential Water Supply(single) ft ft. in.
-
( ° g
-
❑IndustriaUCommercial ❑Residential Water Supply(shared) 18.GROUT -
FROM TO MATERIAL ` D(PI ACEMZN T METHOD&AMOUNT
❑Irrigation
Non-Water Supply Well: 0 •
ft 20 f. Concre:e Gravity-Flow
❑Monitoring ❑Recovery ft. ft
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACE(Ifapplicahic)
FROM TO MATERIAL j EMPLACEMENT METHOD
❑Aquifer Storage and Recovery 0 Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
ft. ft
❑Experimental Technology ❑Subsidence Control ' t
20.DRILLING LOG(attach additional duee:if 9)
❑Geothermal(Closed Loup) °Tracer FROM TO DESCRIPTION(color,hardness,soliRoclt type,gram she,de)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 70 .ft C d.
ft � ft clay,
1 �2
4.Date Well()Completed:7/34 Well ID# /D �Q�,l�S
ft 75 ft l rr to,/�
5a.Well Location: i
J S it 3c 5 ft 6-iv(Ai/ c
j l)r1-1 l-t ra rest I Yl ft ft
Facility/OwnerName. FacilityID#(if applicable) ft .�.,�..'a.,
i,;
4 G Tht- 4-t r Lacinc F r k-ChL a 8 73 s ft ft ' 1 i 2024-
Physical Address,City,and Zip 21.REMARKS
tAnC3lrr,(O-. 9 fn-7 5/4 8. 966 ' - w--- - 'Jt,>•
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minuteslseconds or decimal degrees:
(dwell field,one lat/long is sufficient) 22.Certification:if /'
3s�y 1)113 ' N ��'.ZG a.c,3 va,' W k/� 2.72A,z
Sig of ' eel Well Contractor
6.Is(are)the well(s): 21eimanent or ❑Temporary
By signing this Dorn;I hereby certify that the rxA(s)was(were)constructed in accedence
with 15A NCAC 02C.0100 or 1SANCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or (W copy of this record has been provided to the well owner
If this is a repair,fill out!mown well construction information and explain the nahire of the
repair wader#21 remarks section or on the back of this faro. 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 iMection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 3 $S ($,) 24a. For All Wells: Submit this form within 30 days of completion of well
For muhipk wells list all depths if dffere rat(ezmnple-3(4.200'and 2 c1100') construction to the following:
10.Static water level below top of casing: AO (ft) Division of Water Qualit3,Information Processing Unit,
If water level is above casing,use"+" 1617 Mal Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. - (a (in.) 24b.F.T.Injection Wens: 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 Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Marl Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 3 0 Method of test Blowing-Rig 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chlorine Amount tj/v oz. completion of well construction to the county health department of the county
,where constructed.
Form OW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013 •