GW1--04178_Well Construction - GW1_20240717

WILL CON,'11ZU(;1'1UIV RECORD For Internal Use ONLY:
This form can be used for single or multiple wells •
1.Well Contractor Information:
14.WATER•ZONES,
Bobby W. Potts FROM TO , DESCRIPTION
Wan Contract&Name it ''3(` ) ft .
NCWC 2028-A ft. ft .
NC WellCondaetorCectificationNumber • IS.OUTER C4SJNr'(it wm .c edw�S�ORTIN$B¢d )
. PROM TO DIAM MER THICKNESS MATERIAL ,
•
Ferguson's Well and Pump, LLC 6 n 5;2 ft. 1', ' [g 4c:cc!
•
Com
parry Name 16.DINER CASING OR T[J NG dow rn)ida
FROM PTO DUMM R T MATERIAL
2.Well Construction Permit#: (L S S- c�h13 — l y. is ft ft m.
List all applicable well crostructtoe penults(i e.County,Slate,Vartanc4 etc.) --
f. ft in.
3.Well Use(cheek well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER '',SLAT l_ THIQ IOISS --MATERIAL •
°Agricultural OMunicipal/Public ft ft in. 1
OGe9thetmal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft n'. C -
1iustlial/Commercial °Residential Water Supply(shared) 1S.GROUT --
FRAM TO MATERIAL " EMPLAnwerrMETHOD&AMOUNT
°Irrigatian
Non Water Supply Well: •
_ 0 ft 20 ft Concrete Gravity-Flow
°Monitoring ❑Recovery ft. _ ft
Injection Well: ft. ft
°Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK Of M olhudidi
°Aquifer Storage and Recovery 0 S2linity Barrier FROM TO MATERIAL EMPL10Elef TMETHOD
ft ft.
°Aquifer Test ❑Stormwater Drainage ft. ft. —
°Facparimeuml Technology ❑Subsidcace Control ' '
20.DRILLINGLOGIal ach additional sheets lfnecessary)
°Geothermal(Closed Loop) °Trace- FROM To - DEt RIPflON(color,!arto.o,'Wracka+[±., da..re)
❑Geothermal(Heating/Cooling Return) °Other(explain under#21 Remarks) 0 ft 2t 0 ft C ct V
4.Date Well(s)Completed: 1/'4/sk Y Well J D# "('' ft
yo ft
Caret
S I11��
/ tit' ft 0 ft 74 lAc-/C
Sa.Well Location: •
RW-Hri,rt,C1( Crave.( .1.5wc4-CO Coft 7 ft G7 rQ 1.(tf C
Facility/OwmrName Facility ID#(if
applicable) �� ft it
3CAAZ S�JCu r rCl lot y G'1GCso„,ti�-- ft ft . . .
Physical Address,City,and Zip 21.REMARKS _--. s• -
Ht•r ere nh cjSPI&Co 3Ot)7 —
County Parcel Identification No.(PIN) JL t J
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: i, r'� -
(if well field,ore let/ong is sufficient) 22.Cerli5r8tion U L ..
3s`j'c/ r// -r., '' N_ 5-ACA)N1 a. / c/ " W '"4 /(/ ��y / / .
Sig ofCerti.55&VV<7dl Contractor r, Date/ / y
6.Is(are)the walks): t .irmanent or ❑Temporary By signing this form,I hereby certify But the we (s)was(were)constructed In accordance
with I5A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Consducdiar Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONO----
N copy of this record has been provided to the well owner.
.(f this is a repair fill out brown well eavubuctton trformation and explain the nature of the
repair render#21 remarks section or on the back of this fame 23.Site diagram or additional well.details:
You may use the back of this page to provide additional well site details or well
&Number of wells constructed: / construction details. You may also attach additional pages if necessary.
Forewdtiple bpoctton or non-water supply wells ONLY with the sane contraction,you can
submit one farm. SUBMITTAL INg1'UCTIONS
J 9.Total well depth below land surface: 7t' 3 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multipk wells list all depths tf e,f)$rout(e aflple.3@200'and 2Q100') construction to the following:
10.Static water level below top of casing. 2 G ; (ft.) Division of Water Quality,Information Processing Unit,
.jf water level's above casing use"+" 1617 Man Service Grater,Raleigh,NC 27699-1617
11.Borehole diameter i` (/Q Om) 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 Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a Yield(gpm) Method of test Blowing-Rig 24c For Water Supply de Inieetlon 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: 1 OZ. completion of well construction to the county health department of the county
Y�l where constructed
Form OW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013 •