GW1-2022-06318_Well Construction - GW1_20220705

WILLL LU1Va'1.1tUC;'1101N RECORD
For Internal Use ONLY:
Thus form can be used for single or multiple wells
I.Well Contractor Information:
BobbyW. Potts 14:.WATERZONES:
. FROM TO I DESCPHMON
Well Contractor Name ft ft
NCWC 2028-A ft ft
NC Well Contractor Certification Number 15.OUTER CASING for multi-ca4adwas OR LINER fif ble
PROM TO DIAMETER THICKNESS MATERIAL
Ferguson's Well and Pump, LLC ft136 ft
Company Name IC INNER CAS114G OR TUBING dosed-loon)
FROM I TO D14NIM TR. THICKNESS MATERIAL
2 Well Construction Permit#: 26 2 I - 6 b51-G{t•
List all applicable well constnxiton permits(I e.County Stale,4artmrce,etc.)
ft ft in
3.Well Use(check well use): 17.SCREEN-
Water Supply Well: FROM TO DIAMETER SLOT SIZE THIt HISES3 MATERIAL
❑Agricultural EScapal/Public ft ft in.
❑Geotheal(Heating/Cooling Supply) esidential Water Supply(single) ft ft
rm m
❑Industrial/Commercial ❑Residential Water Supply(shared) It GROUT., _
FROM TO MATERIAL EMPLACEMENT 11WMOD&AMOUNT
❑Irri ation 0 ft 20 ft Concrete Gravity-Flow
Non-Water Supply Well: ft. [t
❑Monitoring []Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK.fif awlicaldc)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL XMPLACEMENT➢WM0Dft. ft c
s
❑Aquifer Test ❑Stotmwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control e B
20:DRILI II'IGLOG:attach ad�gT-olk if
❑Geothermal(Closed Loop) ❑Tracer FROM To DFB IUMON color,hardo solttrodc size,etc
❑Geothermal(Heating/Cooling Return) ❑Other( lain under 421 Remarks) 1 6
ft 2-0 .ft
ft 4.Date Well 190 It.Completed: 0 � Well lD# ft 6 R
52.Well Location: ft- ft Q w ,t
Faciliit(tty�y/Oi r erblame Facility IB#(if appplieable) ft ft
ft ft :.0 Z-4
Physical Address,City,and Zip 2L REMARIG
:IS$ b c �(v l�1 � 3(� !
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Ce tioa:
(if well field,one laUloag is sufficient)
N 2 2,0 3 �$ � W Ax
—n Signature ofC cd W r to
6.Is(are)the well(s): 0frerinanent or ❑Temporary By,rim this fore;I hereby cer*that the wells)was(were)constructed M accordmree
with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or QNo copy of this record has been provi&d to the well owner:
If this is a repair,fill out known well construction b ormadion and explain the nXm of the
repair under 421 rranwb section or on the back of thisfmm. 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 multtple tryectron or non-water supply wells ONLY with the same construction,you can
submit w:eform p SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 9t-s (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if cif fer an(ermnple-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (fL) 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: 62 (in.) 24b.Yor 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
IZ Well construction method: ry construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injectio*Control Prpgram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
132.Yield(gpm) 'L Method of test: Blowing-Rig 24c-For Water Srrpnly&Iniection Wells: In addition to sending the form to
the address(es) abotm, 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.
Form M-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013