GW1-2021-05889_Well Construction - GW1_20211025

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14 WATER ZONES
Bobby W. Potts FROM TO I DFSCRWITON
Well Contractor Name R fi
NCWC 2028-A ft ft
NCWe1lt onuactorCertificalionNumber MOUT'ERCASING o$mnitiesbedwelb OR LINER bk
PROM TO DIAMETER TTIICSNESS I MATERIAL
Ferguson's Well and Pump, LLC n fur.• w Z
Company Name 16 G ORTU131NG,
/� FROM TO DIA11thTFR' TBICKNFS4 MATT1tIAL
2.Wefl Construction Permit#: of 4 1- 6 6 a&M ft. ft. �
List all applicable well construction penntts(e.Comity,Site,Yakamcg etc.) R ft R
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO I DIAMETER swr SIZE I nucE flm MATERL4L
ft ft in,
❑Agricultural ❑Munict lic
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft is
❑Industnal/Commercial ❑Residential Water Supply(shared) 1&GROUT
FROM TO MATERIAL EMPLACEMENT MTMD dt AMOUNT
01ni lion 0 rt 20 tt Concrete Gravity-Flow
Non Water Supply Well: & ft
❑Monitoring ❑Recovery
Injection Well: iL ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK e
FROM TO MATERIAL g1,fpLACEMENTi\iETHOD
[]Aquifer Storage and Recovery ❑Salinity Barrier ft
❑Aquifer Test ❑Stormwater Drainage ft, ft
❑Experimental Technology ❑Subsidence Control
20 DRILLffiG LAOG>itt adi>if it ttlirte(is if
❑Geuthamal(Cluscd Luup) ❑Tracer FROM TO DFALItWntnvolor hardness,sdlh«Q fte,ffalft dze,ets
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remark-M.Remark-M . G ft ft a
ft. 00 ft.4.Date Well(s)Completed: � /�/ Well I[?#
-/ _ ft 1 ft
Sa.Well Location: R ft s er
sc,041 ( l h 1a ft ft
Facility/Owner Name Facility iD#(if applicable) ft ft.
/' K ft
Physical Address,City,and Zip 2L REMARKS
s.Ing Un
County Parcel Identification No.(PIN) 100IM3 $ection
56.Latitude and Longitude in degrees/minateilseconds or dedmal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
r
-3Sl Z3'2 t4o?A ,, N SR2� YS 1O266 q6z�/� W �4k azd,&� �15/2
�T. _- Signature f fied W 1 n for
6.Is(are)the well(s): 04rmanent or ❑Temporary By ytVwW may.form 1 hireby certify that die we (s)was(were)cortstrrocted in accordance
with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Constrwfiorr Stardads and that a
7.Is this a repair to an existing well: ❑Yes or Cho copy of dus recadhas been provided to else well a~..
$this is a rr pair,fill out brown well construction b#bmw1on and explain die nature of dre
repair corder#21 annals section or on tee bade of dmis form 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: construction details. You may also attach additional pages if necessary.
For rmmldple byectim or non-water supply wells ONLY with the same construcdarr,you can
submit are fam SUBrAMAL INSTUCTIONS
9.Total well depth bebw land surface: 3,6S (tit) 24a. For All Wells: Submit this'form within 30 days of completion of well
For multiple wells list all depda if&ffererd(e:m Wk-3@200'and 2Q100� construction to the following:
Division of Water Quality,Information Processing Unit,
10.Static water level below top of caning: 6� (ft) � ty �
If water level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. - (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(gpm) 5 Method of test. Blowing-Rig 24c.For Water iniv&In'ectiati Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b Disinfection type: Chlonne Amount OZw 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-DFvision of Water Quality Revised Jan.2013
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