GW1-2021-05896_Well Construction - GW1_20211025

W LL LL UgJ1NN l KU U l lU1N KELUKU For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts FROM4 R TON MWRIPITON
ft ft
Well Contractor Name f
NCWC 2028-A ft. ft. j
NC Well Conbactor Certification Number 18.OUTERCASI NG oemnifi-ca edwelts ORLiNER d
FROM TO DIAMETER 4 TH[CSNESS I MATERIAL
Ferguson's Well and Pump, LLC 0fL K ft- 16, 7,S'- I Z f ,
Company Name 16ANNERCAMGOR I G&EgftKA dosed
^ C�y� FROM TO DL4NWrER MECKNESS MATERIAL
a
L Well Construction Permit#: V - ft ft 1.
List all applicable well construction pemcts rLe.Cow#y;'State,Variance,etc.)
ft ft in.
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THIC10FM MATERIAL
❑Agricultural to] ipal/Public ft ft in
❑Geothermal(Heating/Cooling Supply) 12 esidential Water Supply(single) ft ft in.
❑Industrial/Commercial []Residential Water Supply(shared) M GROUT
FROM TO MATERIAL EMPLACEMENT METHOD tit AMOUNT
Non-Water Supply Well: 0 ft 20 ft Concrete Gravity-Flow
ft ft
❑Monitoring ❑Recovery
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 19..SAND/GRAVEL PACK. . e
FROM TO MATERIAL EMPLACEMENT AWI'HOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft
❑Aquifer Test ❑Stormwater Drainage &
❑Experimental Technology ❑Subsidence Control
2t1 DRII.i,ING'LOG:apadi additigoal meets if
❑Creothcrmal(Closed Loup) ❑Tracer FROM To DESCRIPITUN odor hudn WbV=k d2e,etc
❑Geothermal aleatin ooling Return ❑Other(explain under##21 Remarks) oft ft a
4.Date Well(s)Completed:jeer// Well ID# ft 2-5- ft
2-5 ft 2 1 ft .c of
Sa.wen Location: tc ft ff
Cti4rk rAASseY, & rt
Facility/Owner Name Facility M#(if applicable) ft ft
3I Eller Ib11 ow rl-� WfFr rVp (K �SS�S-( ft ft Lok
Pbysical Address,City,and Zip \
iAnrombe �I �rJ I b91 �-asyo
County Parcel Identification No.(PIN) VIP
\m
5b.Latitude and Longitude in degreeshsmiutes/seconds or decimal degrees: 2L Certification:
(ifwell field,one latnong is sufficient) 1
VO r �� N �2,�3/ .Sgfanrw
Sigmhre sea well Contracts to
6.Is(are)die well(s): 4.mcnt of ❑Temporary By s#grmrg this fom I*re&certify that the well(s)was(were)constructed in accordmrce
with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 We11 Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 6Fo copy of this record has been prati&d to,the well owner.
If this is a repair fill out known well construction#nfomat#on and erpkin the nature of&
repair under#!21 remarks section or on the back of this fwm. 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 wens constructed: 1 construction details. You may also',attach additional pages if necessary.
For multiple nyection or non-water supply wells ONLY with the sane awnstrturian,you can
submit one form SUBMITTAL INSTUMONS
9.Total well depth below land surface: Z2 (ft.) 24. For All Wells: Submit this form within 30 days of completion of well
For mzdbpk wells list all depths#f delfferrnt(exanpk-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: W n A) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
i
11.Borehole diameter._ ��(in.) 24b.For Infection wells: In addition to sending the form to the address in 24a
above, also submit a copy of this form within 30 days of secon of well
11 Well construction method: Rotary construction to the following: co
(i.e.auger,rotaM cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-16M
13a.Yield(gpm) Method of test: Blowing-Rig 24c.For Water Supply&Iniection•Wells: In addition to sending the form to
r the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chlorine Amount 7�� OZ. completion of well construction to the county health department of the county
where constructed
f
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013