GW1--06823_Well Construction - GW1_20241115

rrLLL L,vi1►7LitUt"1Jilin EMIL.L_PIIJl For Internal Use ONLY: '
This form can be used for single or multiple wells
1.Well Contractor Information: I 1 .
Bobby W. FR Potts
0 WATER TONES DESCRIPTION .
Well Contractor Name ft /�1 /D ft
- ' NCWC 2028-A ft. ��f 0 ft
NC Well Contractor Certification Number 15.OUTER CASING(far niniti-:aced wells)OR LINER(if applicable)
•
FROM TO DIAMETER THICKNESS MATERIAL -
• Ferguson's Well and Pump, LLC 0:-.ft /1S ft G,,,;$1.4 2J6,1A�Pr(5P AZ/
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop) •
O
II ,' T FROM TO DIAMETER ' _ THICKNESS • MATERIAL• .• •
2.Well Construction Permit#: a K ' O U ft ft • 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' SLOT SIZE THICKNESS MATERIAL _
ft ft in
Mun
• ❑Agricultural Oicipal/Publio '
❑Geothermal(Heating/CoolingSupply) tdential Water Supply(single) ft • ft in.
PPP) �Kees
•
-
0 Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT .
❑Irrigation • Q ft
Non-Water Supply Well: 20 ft Concrete Gravity-Flow
• ft- ft.
❑Ivionitoting ❑Recovery
Injection'Well: ft. ft. ,
❑Aquifer Recharge 0 Groundwater Remediation 19.SAND/GRAVEL PACK(If applicbl)
❑Aquifer Storage and Recovery OSalinity Barrier FROM . To MATERIAL EMPLACEMENT METHOD '-1
ft. ft
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology •❑Subsidence Control fr. ft
20.DRILLING LOG(attach additional sheets if necessary)
❑Geuther nal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness.solllrock type,grain she,etc.)
❑Geothermal(Heating/Cooling Return) DOther(explain under# 1 Remarks) Q It fO ft :0/,a1 •
4.Date Well(s)Completed: IO7o�f/a•y W ell IOW 90 fr. -//0 ft. S�t Q ,,,�Q y*�,c
//0 ft /!S ft a lot/6 .
5a.Well Location: .
(1 t ft yet ft r.ivi id i ise.
C.J/tek,1 4 /r ne?t /L1(41e' ft. ft
Facility/Owner%wnne/r Name / Facility lD4(if applicable)
it ft Se t' - y
ft
•
Physical Address,City,andZZip 21.REM RIfS A- 1 ' 2024•
County- Parcel Identification No.(PIN)
•5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
'. � e i
Se3� I Is�.6�Oe2y N $A o3?13 �r�7AY W :/�/ !.�
Signature of Cer'red Well Contractor Da e
6.Is(are)the well(s):• ertttanent or ❑Temporary • By signing this ferny,Thereby 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 E.11 - 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#21 remarks section or one the back of this fonn. 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 injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: TO s (ft.) 24a. For All Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3 700'and ,construction to the following: ' .
10.Static water level below-top of casing: I/O (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617 •
I
11.Borehole diameter: ti r. 4 (in.)' 24b.For Injection Wells: In addition to sending the form 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, pZ Method of test: Blowing-Rig 24c.For Water Supply&Injection Wells: In addition to sending the forth to .
I . the address(es) above, also submit one copy of-this form within 30 days of
13b.Disinfection type: Chlorine Amount: ' • OZ. completion of well construction to the county health department of the county
where constructed.
Form GW-1- - North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013