GW1-2022-06316_Well Construction - GW1_20220705

WZLL UUfNN_1KUl;11UiN KI+f UUKD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
BobbyW. Potts 14.WATEItZONES1: . ....
FROM TO M DESCRIPTION
Well Contractor Name ft /)ft
NCWC 2028-A & v ft
NC Well Contractor Certification Number IS.OUTER CASING(for mulfi-cuedwe OR LINER Cifff
Ferguson's Well and Pump, LLC EOM ft- TD DJAMETM THICKNESS MATERML
r Al /
Company Name 16.INNER CASING OR TUBIrIG'; e3ased-loo
ZO I ! FROM TO DIAMETER 7MCENF4S MATERIAL
2.Well Construction Permit#: ` 660 E ft ft in
List all applicable well construction permits(i.e.County State;Varraice,etc.)• ft ft in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMEM SLOT SM I THICENM f MATERIAL
❑Agricultural ❑Ivhruicipal/Public ft ft in
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft in
❑Industrial/Commercial ❑Residential Water Supply(shared) 1&GROUT:.. _
❑Irri ation FROM TO MATERIAL EMPLACEMM I%MMOD&AMOUNT
Non-Water Supply Well: 0 ft 20 rt Concrete Gravity-Flow
❑Monitoring ❑Recovery ft ft
Injection Well: & ft
❑Aquifer Recharge ❑Groundwater Remediation [..2d:DREUJNG
9.SAND/GRAVEL PACK . e
ROM TO MATERIAL EMPLACEMFISTriEIIIOD
❑Aquifer Storage and Recovery ❑Salinity Barrier & &� ,
❑Aquifer Test ❑Stormwater Drainage ft. &
❑Experimental Technology ❑Subsidence Control m
LOGt�
a 'ad�itinaal slieels if❑Geothermal(Clused Loup) ❑Tracer ROM TO DESCTtIP1TON color hardness,saturoclt Vain die,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 1 0 ft 0 .ft ce 1
ft f ft
4.Date Well ID
s)Completed: Well # ft � ft �.
5a.Well Location: /y d rt tt �U W
L�akzaa ft ft
v_.
FacilitylOrovner.Name Facilityll3#(ifapplicable)
& ft.1 ,fir ry VW .28 736 ft rtZ02 7
PIrv�Address,City,and Zip v
U.REMARKS.
t,n :Zy q 76 0 Ana
cqm Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: Z2.Certification:
(ifwell field,one Wong is sufficient)
S en- 7 1 W, _-_X1J11A1'1'
SijoatuVafeotifird Well Co / for
6.Is(are)the well(s): ermanent or ❑Temporary By signing this form,I hereby cer*that the wells)way(were)constructed in accordance
with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well ConstruciionStandards rid that a
7.Is this a repair to an existing well: Dyes or Oflo copy of this record has been provi&d to die well owner
If this is a repair,fill out Mown well construction information and explain the nature of the
repair rider#21 remarks section or on the back of thisform. 23.Site diagram or additional well details:
A You may use the back of this page to provide additional well site details or well
S.Number ofwells constructed: / construction details. You may also attach additional pages if necessary.
For nmdttple 09ectton or non-water supply wells ONLY with the same constrrneriar,you can
submit oneform SUBAHTI'AL INSTUCTIONS
9.Total well depth below land surface: MS (fL) 24a For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if d fferent(esmnple-3Q200'wzd 2@I00') construction to the following:
10.Static water level below top of casing: 30 ({t) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (in.) 24b.For Iniection Wells: In addition to sending the form to the address in 24a
Rota above, also submit a copy of this form within 30 days of completion of well
12 Well construction method: ry construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injectiog Control Prlmgtam,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a Yield(gpm) Method of test: Blowing-Rig 24c.For Water Supply&Injection Wells: In addition to sending the.form to
the address(es) above, also submit one copy of this form within 30 days of
Amount
Chlorine S/ OZ. completion of well construction to the county health department of the county
13b.Disinfection type: ,--- where constructed.
Form CAW-1 - North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013