GW1-2021-07949_Well Construction - GW1_20210809

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14 WATERZOM C !
Bobby W. Potts FROM TO DE4C'RWTION
Well Contractor Name ft f
NCWC 2028-A ft ft
NC Well Contractor Certification Number 15.OUTER G br mefls OR LINER" hie
PROM TO DIAMETER THICM4J= MATERIAL
Ferguson's Well and Pump, LLC ft e !i" Zi / S C-5 Pg 2%
Company Name 16 INNER G OR TUBING.
i,�a - vv FROM TO DIAMETER TmcxNFSs MATERIAL
L Well Construction Permit#: ft ft is
List all applicable well construction permits(le.County,Slate,Varian¢,etc.) ft, ft
3.Well Use(check well use): M St"_REEN
Water Supply Well: PROM To DIAMISTM SLUT Sir& TffiC[t1VER3 MATERIAL
ft ft in
❑Agricultural OMu
picYp's.11public ft
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft iR
❑lndustriaUCommercial ❑Residential Water Supply(shared) 1&GROUT FROM I TO MATERIAL EMPLACjMMgT METHOD&AMOUNT
❑hri tion 0 ft 20 fL Concrete Gravity-Flow
Non-Water Supply Well: ft- ft
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK, . e
FROM TO MATERIAL EMPLACEMENTT% THOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control
M DRILLING LOiG addiflooal rleeb'
❑Geothermal(Closed Luop) ❑Tracer FROM TO DFSCRIPIYON color,saran solurwk dz etc
❑Geothermal(lieatin Coohn Return ❑Other( lain under#21 Remarks ft ft
S ft SS ft
4.Date Well(s)Completed: Well ID# S ft ft
C
Sa.Well Location: ft ft
Oc3h5ArAf)4 rlc EKonornou ft. ft
Facility/Ownnar Name Facility ID#(if applicable) ft R q�
1 t �7 an� t �b f ft
Physical Address ,and Zip 21.REMARKS
ICI c nn UAA (,�CQ��3nlZ'7L13g9ro t) ,it
County Parcel Identification No. Ile
(PIN) 11r J
r. ^3Zitl' -�011
5b.Latitude and Longitude m d utes/seconds or decimal d 1 ngi egrees/nnn degrees: 22.Certification:
(if well field,one lat/long is suf icicat)
Si o Well CHfor
6.Is(are)the well(s): !a'Permanent or ❑Temporary By signing this f-m I hiieby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Wdl Construction Standards and that a
7.Is this a repair to an esisting well: ❑Yes -or .91Vo copy of this record has been provided to the well owner.
If this is a repair fill out brawn well conduction information and explain the natwe ofthe
repair under#21 renm-ks section or on the back of thisfonn. 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 multiple hyaction or awn-water supply wells ONLY with the same consbuc ion,you can
submit areform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surfacr. 605 (tl) 24a. For All Wells: Submit this form within 30 days of completion of well
Fa m uftiple wells list all depda if dl f'er mt(exanple-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: �� A) Division of Water Qualify,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 2769961617
11.Borehole diameter (hL) 24b.For Iieiectiou Wens: In addition to sending the form to the address in 24a
Rotary above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 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 Matz Service Ce�tra,Raleigh,NC 27699-1636
13a.Yield(gpm) Blowing-Rig 24e.For Water Sir &In'ectionlWelis: In addition to sending the form to
Metirod of test: the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chlonne Amountyj OZ. completion of well construction to*c county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environment and Natural Resources-4-li-ion of Water Quality Revised Jan.2013