GW1--06829_Well Construction - GW1_20241115

• WILL 1...U1716IL KUL.I1V1V ton.L;UKD For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
14.WATER ZONES
Bobby W. Potts FROM TO DESCRIPTION
Well Contractor Name ft 300 ft
NCWC 202$-A ft. 5/0 ft.
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable) .
FROM TO DIAMETER THICKNESS .• MATERIAL
Ferguson's Well and Pump, LLC 6...•ft (ov ft, /r� ._Z4.//25 pUC L2./.
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop) . •.
Z, r C'`4,9 9 FROM TO , DIAMETER THICKNESS . MATERIAL'
2.Well Construction Permit#: 2 V �•l` U ft ft
List all applicable well construction permits(i.e.County,State,Variance,etc.)-
ft. ft. in
3.Well Use(check well use): 17.SCREEN
Water Supply'Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL _
❑Agricultural ❑Mwucipal/Public ft ft. in. '
❑Geothermal(Heatino/Coolin Supply) CR tdential Water Supply(single) ft ft in.
.�
❑Industrial/Commercial ❑Residential Water Supply(shared) iS.
FROMGROUT •TO MATERIAL EMPLACEMENT METHOD el AMOUNT
❑Irrigation 0 ft ft
Non-Water Supply Well: 20 Concrete Gravity-Flow _
❑Monitoring ❑Recovery ft ft .
Injection Well: ft ft.
❑Aquifer Recharge 0 Groundwater Rernediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft ft
❑Aquifer Test ❑Stormwater Drainage
ft. ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM, TO DESCRIPTION(cutor,hardness.soIi/rock type,grain size,etc)
❑Geothermal(Heating/Cooling Return) DOther(explain under ii2I Remarks) ,Q ft . ft ,e day
4.Date Well(s)Completed:/4 gl.y Well UN .
9 ft 90 ft Sug,57(B�e •
5a.Well Location: 10ft. /M ft i1 J a /C
t / 1,2ftk0c.,ft 6• �P' c
F c el- 14Otdt.114S.Li C.- ft. ft
Facility Owner Name Facility III(if applicable) •
ft ft u "" `O 'r `+
A
•
(- a'6 Pi n A-5kg,o;t t�zSsfsa ft ft. NOV I '1174
Physical Address,City,and Zip 21.REMARKS.
(A.i/l�-)m b.Q 628 -7s-542 1 l r` ..,.,:.y:. ? ,• ,•__r,, •
County Parcel Identification No.(PIN) •°'t.e t.,.:i
5b.Latitude and Longitude in degrees/minutes/seconds or derirnal degrees: 22.Certification:
(if well field,one let/long is sufficient) I
�f� /3s o3/ I,P.Sh Y"r -N &a,/ 'i 7& 2/• wr afCerpfied nice, fiat r Du
6.Is(are)the well(s): ermanent or '❑Temporary By signing this form I hereby certify that the well(s)was(were)constructed in accordance
with ISA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 0No 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 421 remarks section or on the back oflhtsform. 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 ityection or non-water supply wells 0 LY with the same construction,you cm:
submit onefornc SUBMI4TAL•INSTUCTIONS
9.Total well depth below land surface: (ft.). 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdbferent(example-eS0`.and 2@100`) construction to the following:
10.Static water level below top of casing: _Ca (ft,) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" II 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: j, lQ (in.)' 24b.For Infection 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(gpm) 6 Method of test: Blowing-Rig 24c.For Water Supply&Injection Wells: In addition to sending the form to ,
the address(es) above, also submit ones copy of this form within 30 days of
13b.Disinfection type: Chlorine Amount: SOS Qz, 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