GW1-2021-05944_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'n DESCRIPflON
Well Contractor Name ft
NCWC 2028-A M ft
NCWetIConCaetnrCertificationNumber IS OUTER CASING armnl4rt�edt+rAs t)RLiNER d
FROM TO DIAMETER TMC NM MATFRJAL
Ferguson's Well and Pump, LLC I Ar SPIN/
Company Name 16.INNER CASING OR G. lased
FROM TO DIAMETER TH1Ci{NE4s MATERIAL
2.Well Construction Permit#:�� 166116 740 ft k
List all applicable weA construction permits(r.e.Cormiy,Slate,Variance;etc.) tt n
3.Well Use(check well use): ff SCREEN
Water Supply well: FROM TO DIAMETER 11
SLAT SME [3 THiC MM MATERIAL
ft & in
OAgricullural in, —4—
❑ pallPublic
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft
❑ladustrial/Commercial OResidential Water Supply(shared) M.GROUT
FROM TO MATERIAL , CF1MTr METHOD de AMOUNT
01maation 0 ft 20 ft Concrete Gravity-Flow
Non-Water Supply Well: ft ft
❑Monitoring ❑Recovery
Injection well: ft ft
❑Aquifer Recharge ❑Groundwater Remediatiou 10.SAND/GRAVEL PACK Of spolighle
FROM TO I MATERIAL I EMPLACEMEIVTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier & ft
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control
ZO:DRII.LIN&LOG zpadi adit?noil dneEtit
❑Creutheamal(Closed Luup) ❑Traucr FROM TO DESC'Rlti'IION color hardness,soluroctt Wir,Olin she,eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) ft O tt a
ft G ft. 51 ��
4.Date Well(s)Completed: Well ID# ft ft
Sa.Well Location: ft-
ft ,
_/�) (A/7.S�iitrian PLC t ft
Facility/Owner Name ,I Facility ID#(if applicable) ft ft
i-"• l im vie,, /.rP H—.Sfy)r�i l ft: _ ft ft 5
Physical Address City,and Zip' 2L REMARKS
�P IPrSon D(o(��9k�S51 nPaA n
County Parcel Identification No.(PIN) I1 0
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lWong is sufficient) "
°
l x
fled Well atrac r to
6.Is(are)the well(s): Crmanent or OTemporary
By stgrcng this farm.1 Irzrreby eero;/y Bra the weU(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or I U NCAC 02C.0200 Well Construedon Standa ds and that a
7.Is this a repair to an existing well: ❑Yes or OKo copy of this record has been provi&d to The well owner.
If this is a repaln fill mil lbwwn well construction b#onnatlon and explain the nature of tine
repair under#21 ranks section or on the back of dntsfmm 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 rmdhple iryacuon or nor-water supply wells ONLY with the sane oonshuc tar,you can
suhn*onefo"n, SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: M/7.5. (g) 24a. For All Wells: Submit this form within 30 days of completion of well
For—Idple wells list all depths ifal er nt(example-3 00'and 2@1001 construction to the following:
10.Static water level below top of casing: 9100 (ft) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+° 1617 Mail Service Center,Raldgb,NC 2769961617
It.Borehole diameter.�� (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Rota above, also submit a copy of this foam within 30 days of completion of well
11 Well construction method: Rotary construction to the fulloaing:
(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,Raleigb,NC 27699-1636
13a.Yield(gpm) Method of teat: Blowing-Rig 24c.For Water Subn1v&In'ect�n WeW: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
136 Disinfection type: Chlorine Amount OZ. 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-Dkvision of Water Quality Revised Jan.2013