GW1-2021-01767_Well Construction - GW1_20210430

WLLL I;VMTHUU110N RECORD For Internal Use ONLY:
This form can be used for single or multiple walls
1.Well Contractor Information:
Bobby W. Potts "WNTMZONFs
FROM TO DESCRIPTION
Well Contractor Name ft /T ft
NCWC 2028-A ft. (! M
NC Well Contractor Certification Number OUT'E11WI WING at'mnificased�[d1a ORLWER if h
FROM TO DIAMETER': TIRCHrim MATERIAL
Ferguson's Well and Pump, LLC 0 �/ iR 2 5- Uc 2Z�
Company Name 16.INNER C ASING OR 11rMQ tamodmiratal dosed
�oa� bo 3 83 FROM TO DIAMETER THiCIt aM MATERIAL
2.Wen Construction Permit#: ft ft in.
List all applicable-U construction permits(i.e.Calmly,State,Yariancg etc.)
ft ft in
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER; SLOT SIZE THICKNESS MATERIAL
OAgricultural ft ft in'
❑Munici blic
❑Geothermal(Heatiag/Cooling Supply) esiC dential Water Supply(single) N• ft in.:
❑IndustriaUCommercial ❑Residential Water Supply(shared) -1&GROUT
�Y'
t C Flow
FROM TO MATERIAL EMPLACEMENT METHOD A AMOUNT
❑Iai lion - rc 0 - ft Concrete Grav'
Non-Water Supply Well: 0 2
❑Monitoring ❑Recovm'Y ft ft
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/G3tAVEL PACKdrsualkaVel
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEAUMMMOD
ft ft
❑Aquifer Test ❑Stormwater Drainage
ft ft
❑Experimental Technology ❑Subsidence Control
20 DRII.LII IG ZOG attadi add3taao osl a�esfs K
❑Geuthtumal(Closed Loop) ❑Tracer FROM TO- DESLId ON color hardness,soilhoctt etc
❑Geothermal(Heating/CoolingReturn ❑Other(explain under#21 Remarks 0 tt Z ft
tt ft Q�4.Date Wells)Completed Well 1D#
Sa Well Location: ft s rt
MRuC ft ft
Facility/Owner Name Facility 1D#(if applicable)
5-A- Boa Ar i Jg -WHIJ Asty Ul'tit oK5%p!j tt ft
Physical Address,City,and Zip
�--� 2L REMARKS i, Alm Luc-1
County Parcel Identification No.(PIN) !¢Cvyq'i aEii:1 i ,,--
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 Certification:
(if well field,one lat/long is sufficient)
or
A/
- // S' ed Well true
Of
6.Is(ante)the well(s): BPermanent or ❑Temporary F3 st dds f0rnt I here dmr the wet s was by () (were)constructed in accordance
widr 15A NCAC 02C.0100 or 15A NCAC'02C.0200 Well Construction Stmrdards and drat a
7.Is this a repair to an existing well: ❑Yes or QNo copy of dw record has been pmvi&d to dw well owner.
If this is a repair,dill out known well construction it fonnation mid espk in the nature of dre
repair under#21 ronmlcs section or on the bout:of AW form 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.
For multiple injection or nova-water supply wells OATY with dw same cons&ucdom you can
submw core form t SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: SO (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells/at all depths ifdrfferent(exmaple-3®200'and 2&00) construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Quality,Information Processing Unit,
If water level is above cas g,use ,+,, 1617 Mail Service Centei,Raleigh,NC 27699-1617
11.Borehole diameter. _ On.) 24b.For Iniecdon Wefts: 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
1L 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 Marl Service Cen Raleigh,NC 27699-1636
13a Yield(gpm) Method of test Blowing-Rig 24�For water Stiruply&Iniection Wells: In addition to sending the form to
the address(es) above, also submit tine copy;of this form within 30 days of
136.Disinfectiontection type; Amount:Chlorine OZ. completion of well construction to the lcounty' health department of the county
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Qua I lity Revised Jan.2013