GW1-2021-05966_Well Construction - GW1_20211025

n'L'LL 1,V1\►71 RLU1,11V1V Kl IL%iKL For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts 14.WATERZONEs t..i
FROM TO I DFSCRI1MON
Well Contractor Name ft ft
NCWC 2028-A & Wy ft
NC Well Contractor Certification Number IS OUTER CASING ormnlfrcasedwed&b OR LINER d' ale
FROM I TO DIAMETER T1DCID'rESS MATERIAL
Ferguson's Well and Pump, LLC �. ft
Company Name 16.14NER G OR TUBING.6eadiermal domd4pon)
,�0 FROM TO DIAMETER imcxNFSSS MATERIAL
2 Well Construction Permit#: ft ft is
List all applicable well construction per»u r ts .e.County,Store,Variance,etc.)
ft ft in
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMEfF.R SLOT SIZE TFaCKN= I MATERIAL
ft ft in
❑Agricultural ❑M�nic' blic
❑Geothermal(Heating/Cooling Supply) esiC�Ff dential Water Supply(single) ft ft in.
❑lndustnal/Commercial ❑Residential Water Supply(sham 18:GROUT
FROM TO MATERIAL , EMPLACHVIEN'1'MEIIiOD S AMOUNT
Nonn--Waate
❑ ter Supply
Well. 0 rt 20 n• Concrete Gravity-Flow
❑Monitoring bRccovcry
ft ft
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19..SAND/GRAVEL PACK rEr mmAicsWel
FROM TO MATERIAL EMPLACERENTAWIROD
❑Aquifer Storage and Recovery ❑Salinity Barrier R ft
❑Aquifer Test ❑Stormwater Drainage & ft
❑Experimental Technology ❑Subsidence Control
X DR[LLING LOG:2#Mb additional'chests if
❑Geothermal(CIL*rd Luup) ❑Tracer mom TO DESCRIMON r hardness,sWbymlt etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) I ft 64 ft a
ft ft
4.Date Well(s)Completed: 1�� Well 1D# ft ft
149 C
Sa.Well Location: R tt
e
ft ft
Facility/Owner Name Facility ID#(if applicable) ft ft
��q C�c>brirlC �>anP t'11i�r„Sh�l1 ?Sy & ft
Physical Address,City,and Zip
21.REMARKS.
1')2 Ci IQlig 1(e 3(P316 tl('.T
County Parcel Iaeatification No.(PIN) eS51n9 n
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: (n Of ' R section
ifwell field,one lat/lo 22.Certification:
( d ng is sufficient) 0w
'12
// rT Sigmture f eel Well ntrac r Date /
6.Is(an)the well(s): gFermanent or '❑Temporary
By sigmng this form,194 eer*that the weA(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ® copy of thus record has been provz&d to dw well owner.
If this is a repair,fill out known well construction information and eVim the nature of the
repair under#21 remarks section or on the bark of this form. 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 upection or non-water supply wells ONLY with the same constraebavi you can
sabnut one fans. SUBA=AL 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 depdas if a5 erent(xanple-3 00'aid 2@100D construction to the following:
10.Static water level below top of easing: �/� (g) Division of Water Quality,Information Processing Unit,
If water Level is above casing,use"+ 1617 AM Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (in.) 24b.For Iniection Wells: In addi iim to sending the form,to the address in 24a
Rota above, also submit a copy of this!form within 30 days of11* etion of well
12.Well construction method: Rotary construction to the following: "\
(i.e.auger,rotary,cable,direct posh,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-16M
13a.Yield(gpm) Id, Method of test: Blowing-Rig 24c.For Water Supply&Iniection Wells: Jn addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b Disinfection
typ Chlorine jea�OZ completion of well construction tot the county health department of the county
a Amount: where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013