GW1-2021-05898_Well Construction - GW1_20211025

wibLLl.y11431KU1.11V1l111 EC:UIUJ For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts FROM4R To I DESCRiYfJON
Well Contractor Name ft
NCWC 2028-A & ft
NC Well Contractor Certification Number M OUTER CASING for wells OR LINER it
FROM I TO DL4MEM 7MC10ECS MATERIAL
Ferguson's Well and Pump, LLC ft rt t in
Company Name 16.-INNERCASMORTUBING. adined
FROM I TO I DIAMErFR THICItTi SS MATERL4L
2.Well Construction Permit#: 61 oa. ^ 6631 (P . - tt ft hL
List all applicable well construction permits(i.e.Cotmty,'State,Variance,etc.)
2 R in.
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM 775 DIAMETER SLOT SIZE I THICKNESS I MATERIAL
❑Agricultural ❑ pal/Public ft ft in
❑Geothermal(Heating/Cooling Supply) C esidential Water Supply(single) R ft m.'
❑Industnal/Commercial ❑Residential Water Supply(shared) 11L GROUT
FROM TO MATERIAL EMPI ACHOIFIV f METHOD&AMOUNT
❑Irri ation
Non-Water Supply Well: 0 ft. 20 Concrete Gravity-Flow
ft ft.
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PA C1 - e
MATERIAL nVLACEMIENTAWMOD
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO ft. ft
❑Aquifer Test ❑Stormwater Drainage R ft
❑Experimental Technology ❑Subsidence Control DRILLffiG LOG attsdi additional sbrses
❑Gcuthermal(Closed Loup) ❑Traut:r FROM TO DESLItIPTION cdor,hardness,sottnoctr etc
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) I ft-
t ft
fa ft 4.Date Well(s)Completed: Well ID# ft- 116 ftaa.Well Location. ft ft r C
A,l mor(ar, ft. ft
Facility/Owner Name Facility 1D#(if applicable)
Luck
ft ft
�u-��1 ha 6 C�O
r u!T 1-r!1;,,,1ew aBl3 o ft ft o
Physical Address,City,and Zip 21-REMARKS
—buylCt>rY►I,r qLa Kiln 0(o(0.2 1 �a �g5
County Parcel IaentificationNo.(PIN) �3C10 CJgC
Sh.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/longg is sufficient)
Sijnamk of find a for to
6.Is(are)the well(s): QPermanent or ❑Temporary
• BY signing thts form I.T &certify that the well(s)was(were)constructed to accordance
with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construcdon Standards and that a
7.Is this a repair to an existing well: Oyes or o copy of this record has been provided io,die well owner.
1f this is a repair,fill mat brown well construction itfornration a nd explam the nature ofthe
repair render#21 remarks section or on the back of tW 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 hyecttan or tort-water supply wells ONLY with the same cons&uchm you can
submit ore form SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: A�aS (fL) 24a. For All Wells: Submit this form Nvithin 30 days of completion of well
For nmlhple wells list all depths if df'erem(c=nple-3@200'and 2@1001) construction to the follovvrg:
10.Static water level below top of casing: fo ({t,) Division of Water Quality,Information Processing Unit,
Ifwater level is above casing,ure"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter._�(in.) 24b.For Injeetion Webs: In addition to sending the form to the address m 24a
Rota above, also submit a copy of this form within 30 days of co secon of wzll
12.Well construction method: ry construction to the following:
(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,Rabdgh,NC 27699-16M
131.Yield m —r / Blowing-Rigc. or at Supply I Witter uppy& niection Wells: In addition to sera
(gp ) /� Method of test: 24 F W ding the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chlorine Amount: OZ. completion of well construction to the county health department of the county
where constructed.
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Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013