GW1--06795_Well Construction - GW1_20241114

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VVJi L4 l.U1ViJii(U�.i1U1' t{ ,ca.) tl•
'. For Internal Use ONLY:
This form can be used for single or multiple wells •
1.Well Contractor Information:
14.WATER ZONES ' 1
• Bobby W. Potts FROM TO DESCRIPTION •
. Well Contractor Name ft A to ft
NCWC 2028-A ft 3 Z.0 ft
NC Well Contractor Certification Number 15.OUTER CASING(for multi-e:,sedlwells)'OR LINER(if applicable)'
FROM TO DIAMETER THICKNESS- MATERIAL
Ferguson's Well and Pump, LLC t).--.ft F .ft' 6;AS in" 2/b 11' f UCSD,/
Comt>ny Name 16.INNER CASING OR TUBING(geothermal closed-loop) •
FROM TO DIAMETER : THICKNESS •MATERIAL
2.Wei Constriction Permit//: b'S S -' 00 e244, (�L1540 ft ft I in
List all applicable well construction permits(i.e.County,State,Variance,etc.) - in
ft ft •
3.Well Use(check well use): 17.SCREEN •
Water Supply Well: FROM . TO. .' DIAMETER I. SLOT SIZE. .THICKNESS MATERIAL. .
ft. ft. 'in.
❑Agricultural ❑Mut• pal/Public•
DGeothctmal(Heating/Cooling Supply) esidential Water Supply(single) ft ft in,
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO - MATERIAL ElveLACEMENT METHOD&AMOUNT
❑Imgation 0 ft 20 ft concrete . Gravity-Flow
Non-Water Supply Well:
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❑Monitoring ❑Recovery ft ft:
Injection Well: ft ft
❑Aquifer,Reeharge ❑Groundwa ter Remediation 19.SAND/GRAVEL PACI (if applicable) •
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD •
ft ft . ,
❑Aquifer Test ❑Stormwater Drainage '
ft. ft -
❑Expersmental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geuthermal(Closed Loop) ❑Tracer FROM. TO • DESCRIPTION(color,hardness.soitlrock type,grain'she,etc.)
❑Geothermal(Heating/Cooling Return) - ❑Other(explain under r21 Remarks) 6 ft. /_.0 ft n i�y .
: zzm
pleted:(� ��/NellII tion:
8 ft 3k5 ft• .,
tc� F4;O S e0.4_,{-nte•-irwn LLC ft: ft
Facility tuner Name Facility ID#(if applicable) _
,clad Pi•SrPn ►'csr 11a-I(� �-1tnJdr5tsin/Lt(Q.�S7q� ft. ft ._ . .
Physical Address,City,and Zip 21.REMARKS • F'e V 1 %I)'Th
County Parcel Identification No. PIN - - - '..--`'`-'-:•:.--" -.);'
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LiSb.Latitude and Longitude in degrees/minutes/seconds or derimal degrees: 22.Certification: V •
(if well field,one lat/long is sufficient)
� •-( O 7� I N eCp.�• n%h �r �� v -t W j• .
3s (�t�
Signs a of Ce " ed Well ntr for• I •
6.Is(are)the well(s): eaP rtnanent or ❑Temporary ' By signing this an,I here cer that the well(s)was(were)constructed in accordance
�'g f b3�,� with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards Mid that a
7.Is this a repair to an existing well: ❑Yes or J2o copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under n21 remarks section or on the back of thisfornt. 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:. . l construction details.'You may also attach additional pages if necessary. - .
For multiple infection or non-water Supply wells ONLY with the same construction,you can 1
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 3 ,5 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@ 200'and 2@100') construction to the following:
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10.Static water level below:top of casing: 010 (ft.) Division of Water Quality;Information Processing Unit,
If water level is above casing,tire"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: •S _ 6 (in.)" 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: - -Y 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 Ce}ter,Raleigh,NC 27699-1636
' 13a.Yield(gpm) is Method of test: BIOWIng-Rig •24c.For Water Supply&Infection'Wells: In addition to sending the form to
the address(es) above; also submit Ione copy of this-form within 30-days of
13b.Disinfection type: Chlorine Amount: G// OZ completion of well construction to the county health department of the county
Il (Q where constructed.
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Forni G W-I• , North Carolina Departrnent of Environment and Natural Resources—Division of Water Qtlnlity Revised Jan.2013
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