GW1-2021-05946_Well Construction - GW1_20211025

W L'lALJ l.U11q D 1 KU U 11UfN K1+UUKU For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts ZL WATER ZONES I ..r.
FROM TO DESCRI MON
Well Contractor Name ft h F
NCWC 2028-A IL .r�
NC Well Contractor Certification Number I&OUTER CASING 16ow Wells)ORLIKM d bk
'FROM I TO DIA?.MTM 7 MCICNrSS MprEMAL
Ferguson's Well and Pump, LLC >t ;ti
r
Company Name 16..1NNER CASll 4G OR TTTBI.G.
// DIAMETER IMCENFM MATERIAL
2.Well Construction Permit#: tl b I A y L 1 7-7(D ft i in
List all applicable well conslrvction pemdis(1.e.Cototty,'Stame,Variance,etc.)
q ft in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SSIZE I IMCNNM I MATMIAL
ft ft im
❑Agricultural ❑ blic
❑Geothermal Hcatm Coolie Supply) esi�Water S ft ft m:
( g/ B PP Y) uPPiY(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 111 GROUT.- i
FROM I TO MATERIAL Dee ACEMZNT MLrMOD&AMOUNT
Ohn,gation ft. 20 fL Concrete Grav
Non-Water Supply Well: � '�-Flow
❑Monitoring ❑Reco ft ft
`�Y
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACI►, e
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft To MATERIAL EMeLACKMENTAWMOD
ft
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control fL
TDPJLLDFG IAG.attadi additional sbeebs if❑Geothermal(Closed Luup) ❑Tracer TO DEStZtD'1IUN kilos hardn soiUrodt etc❑Geothermal(Heatin oolin Return ❑Other( lain under#21 Remarks ft
v ft4.Date Well(s)Completed: Well ID# b ft
5a.Well Location: Q rL tt a t
�G2MiA fL1t-7 S804jml ft ft
Facility/Owncr Name �1 / '-Facility ID#(if applicable) /� ft. ft.f
q� QOnQIS Lttto t�( 2Z �-Ien8ofSor11 al Z7ga ft ft
Physical Address,City,and Zip I•-1 2L REMARKS
encler&on 9 G,8 I LI l-1(0 902
County Parcel Identification No.(PIN)
11
56.Latitude and Longitude k degreeshninntes/seconds or decimal degrees: 22.Certification IIi¢OIIIt3t'Oil s
(if well field,one Wong is sufficient) ' section
N ��°�2y°aZG1 A/ W
Si of ed Well trac to
6.Is(are)the wen(s): Permanent or ❑Temporary
By sigrm:g form,I k"re&cernfy that the weA(s)was(were)constrrncied in accordance
/" with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Cons1racliori Standards and drat a
'l�0
7.Is this a repair to an existing well: Oyes or 0 copy of ids record has been prmukd to;dw well owner.
If this is a repair,fill out brown well consirtw ion irfbrnration and explain the native of the
repair zmkr#21 rernmlcs section or on the back of this form. 23.She 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 multiple dgection or non-water supply wells ONLY with dw sane cortst}rtc�ion,you can
submit areform 9UBMITrAL INSTUCTIONS
9.Total well depth below land surface: 32s, (ft.) 24a. For All Wells: Submit this form Nvithin 30 days of completion of well
For multiple wells list all depths if c6f jerent("mnpk-3®200'and 2@100') construction to the follovaing:
10.Static water level below top of casing. Yt� (ft•) Division of Water Quality,Information Processing Unit,
$water level ds above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 42 (m.) 24b.For Iniection Weill: In addition to sending the form to the address in 24a
Rota above, also submit a copy of this form within 30 days of cor�letion of well
12.Well construction method: Rotary construction to the folluv ing: ' '1
(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
13s.Yield(gpm) _ Method of test: Blowing-Rig 24e For Water Sunoly&Ino-ti In Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13L Disinfection type: Chlorine Amount: S® OZ. completion of well construction to the county health department of the county
where constructed
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013