GW1-2021-05967_Well Construction - GW1_20211025

W LLL 1.V11401 Kuq-11V1I1 Il LILUMIJ For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor lnformstion:
Bobb W. Potts 14:WATERZONFS ...
Y FROM TO DESCRIPTION
Well Contractor Nameft. t72 Q. .
NCWC 2028-A ft r�
NC Well Contractor Certification Number M OUT'ERCASING or we�a OR LINER d
FROM I TO D14MEM I IMCKnnrec MATERIAL
Ferguson's Well and Pump, LLC 0 ft ft ;n A5
Company Name 16•INNER CASING OR G. dosed
/� ( FROM TO DIAMETER THICKNESS MATERIAL
L Well Construction Permit#: d _ ft it m
List all applicable well construction permits(i.e.Cotudy,'State,Variance,etc.)
tt ft in.
3.Well Use(cheek well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE IMCKNM MATERIAL
❑Agricultural l714unicipattPublic ft ft in
❑Geothermal(Heating/Cooling Supply) ay.-idential Water Supply(single) ft ft
❑Industrial/Commercial ❑Residential Water Supply(shared) 1&GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD a AMOUNT
Ohrigation Non-water Supply Well: fit.
ft 20 It Concrete Gravity-Flow
Ct ft
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Grotmdwater Remediation i9..SAND/M4V13L PACIs e
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery O Salinity Barrier & ft
❑Aquifer Test ❑Stormwater Drainage
ft ft
❑Experimental Technology ❑Subsidence Control 21L DRILLING LOG attach ad&tiaoal sheefs if
❑Geuthermal(Closed Luop) ❑Traecr FROM TO DESLIOPnON rotor huftes4 sell/rock 01w,ffaln die,etc
OCreothermal(Heatin Cooling Return) ❑Other(explain under#21 Remarks) I & TO ft
ft D ft
4.Date Well(s)Completed: �j!J/�/ WellIDN ft ft
5a.Well Location: , K' ft C
�AnQ a -Txre. 09 lei^t'1�� 703 ft ft
Facility/Owner Name Facility ID#(if applicable)
}� 1 / / �(� '/ ft ft
�1 C Q L Cc�.54r nth 7Y -- fc ft
Physical Address,City,and Zip ZL REMARIM
Ch QAA t so e^ 2 7 -1 A —8(v kggagging Unit
county Parcel Identification No.(PIN) n OnxNgSeeiion
5b.Latitude and Longitude in degreeshminutes/seconds or decimal degrees: 22,Certification:
(ifwell field,one lat/long is sufficient)
N w z/
�/ Si of •See Well Con r rc
6.Is(are)the well(s): LaPFermantxit or ❑Tepry
. mora By signing this farnt I liere�y aerlify that the weA(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or ISANdW 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or BIC— copy of this record has been prow&d to der well owner
If this is a repair,Jill out brown well conduction irrjornration and explain the nature of the
repair rouser#21 r m rb section or on the back of thtsfmm. 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 mnlhple hyecucn or non-water supply wells ONLY with dw same consiracam 3vu can
svbP&oneform SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 3(�S (tt) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(exmnple-3@200''and 2@100) construction to the following:
10.Static water level below top of casing: `1
0 00 Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Matz Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (in.) 24b.For Injection WeBs: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Rotary construction to the following: 'e
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY MIMS ONLY: 1636 Mail Service�enter,Raleigh,NC 27699-16M
13a.Yield(gpm) 3(� Method of test: Blowing-Rig 24c.For Water Suooly&lniection 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: Chlorine ,Amount: So QZ, completion of aell construction Itothe 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