GW1--04179_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.WATER-ZONES_
FROM TO • , DESCRIPTION
Well Contractor Name ft 7)
NCWC 2028-A ft ft
NC Well Contractor Cc fication Number 15 OUTER.CASING(for mnlii.easud wens)OR LINER at-applicable)
FROM TO DLLMETER THICKNESS MATERIAL
Ferguson's Well and Pump, LLC 0 f 7 ft. 6 r S bL W4 i )A,S'A`c5 pr2%
Company Name 16.INNER CASING OR TUBING(sti msl dosed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: CSS -a 0 a a - 0 35 a ft ft in.
List all applicable well construction permits(i.e.County,State,Vorimtce,etc)
ft ft in.
3.Well Use(cheek well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICEINFSS MATERIAL
❑Agricultural CIpal/Public ft ft inft
❑Geothermal(Heating/Cooling Supply) tial Water Supply(single) ft is `
❑IndustrialCommcrcial ❑Residential Water Supply(shared) 18.GROUT -
FROM TO MATERIAL ' Ef4PLICEMENTMETHODtitAMOUNT
❑hrigation
Non-Water Supply Well: 0 it 20 ft• Concrete Gravity-Flow
❑Monitoring ❑Recovery ft ft
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediatiou 19.SAND/GRAVEL PACK Of applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHOD
ft ft
❑Aquifer Test ❑Stotmwater Drainage
ft. ft
❑Experimental Technology ❑Subsidence Control /20.DRILLING LOG(attadr adenoma sheets ifmasonry)
❑Geuthermal(Closed Luup) El Tracer FROM TO DESC'RIP'ITON(color,hardness,soil/rock type,grain site,etc)
0 Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) () ft /(� ft C taLi
4.Date Well(s)Completed: Y' /'O ).5f•Well MN L a ft (!•7 d it �f��„(�rl-e
Sa Well Location: / / - 0 ft ,7$' ft flu vdt'(�,la/C�7`-
O►t i.-3 ()6 f -r(rCtl Or) /0 ft. Cr y frt.
paw,' • �
, ft [t
Facilitywocr Name Facility ID#(if applicable)
Li^� 1/ I Imo- I - ft. ft
mn, PSeenSian Vtit(Lj 1-le/Y-I!/cOn✓trlldt)t13 ft ft t '.'a. a.. I s 1..0
Physical Address City,and Zip 2L REMARKS ! 1 7 2021
County Parcel Identification No.(PIN) Ir. -3/1Q: 1J1
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: Cr/`"'tC..
22.Certification:
(if well field,one lat/long is sufficient)
i /
3St:7ZO t3$/763r7(N ?�- 5 & , J7 % 't w - 1iZei Af4 ' / 0/� `l
�� Signature of eel Well Contractor D
6.La(are)the well(s): cut--nent or ❑Temporary By signing this form I hereby certify that the well(s)was(were)constn&oed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Ls this a repair to an existing well: ❑Yes or o copy of this record has been provided to the well owner.
If this is a repair,Jill out brown 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 hyecttar or non-water supply wells ONLY with the sane construction,you car
.submit onefornc SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: r()..5 (ft,) 24a. For Aft Wells: Submit this form within 30 days of completion of well
For multiple wells Ist all depths if thfferent(example- 0'and2@,100') construction to the following:
10.Static water level below top of casing. 2 0 ' (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. i 4 (in.) 241i.For Injection Wens: In addition to sending the fora to the address in 24a
Rotary above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 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 Simply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13k Disinfection type: Chlorine Amoimr 5'1its 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