GW1-2022-06319_Well Construction - GW1_20220705

W LGLL U011 NIRU U 11UN RECURD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts FROM FROM ERZONFS:.
T DESCRIPIITON
Well Contractor Name M ft
NCWC 2028 A ft ft
NC Well Contractor Certification Number is.OUTER CASING(for mplticasedvtells ORLINERd ble
FROM TO DIAMETER THICKNESS MATERIAL
Ferguson's Well and Pump, LLC ft. ft �.)\ ln. 21(t1A_y
Company Name 16.INNER CASING OR TUBING closed-loon)
A FROM TO DIAMETER THICKNESS MATERIAL
7-Well Construction Permit#: ��t�� - (l 0 �o gjT_ ft ft in
List all applicable well construction petrels(i.e.Corotty,'Stat,etc.)
ft ft in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO I DJAmFmR I SLOT SRZE I Tm I wee I MATERL4L
❑ cultural ft ft in
❑ blic
❑Geothermal(Heating/Cooling Supply) esi�Water Supply(single) ft ft in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT..
FROM TO MATERIAL EMPLACIIIIISIPMETHODNAMOUNT'
❑hn at 20 Concrete Gravity-Flow
Non-Water Supply Well: 0 f
ft
❑Monitoring ❑Recovery ft
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL-PACK m
❑Aquifer Storage and Recovery ❑Salinity gamer FROM To ft
MATERIAL EMPLACEMPSif AfETfIOD
❑Aquifer Test ❑Stormwater Drainage c
❑Experimental Technology ❑Subsidence Control ft it
20.DRILLING LOG:attach additiansl dwds if
❑Geuthermal(Cluscd Loup) ❑Tracer FROM To DFSCTtIP'1TON color,hardness,sollfrock etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) I ft 2S ft
u- ft 3 ft
4.Date Well(s)Completed: Well ID#
ft 2 ft `C
Sa.Well Location: - / or/�(
a AI ft 7,03 ft
a—.� ft ft
Facilityf veer Name Facility M4(if applicable) a ? rt
ft
ft
QLJ WCR,t' U4 t1 P °•��4t_- 297734, oft. ft 2Q22
y
Physical Address,City,and Zip —
e to r)C b 9 Jar7 LlQA ?L�r(rL 21 REMARKS. triot g Uri;:
County Parcel Identification No.(PIN) ✓. .r
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:(if well field,one lat/long is sufficient) :
IS
i S `/t1 N S 7, zS` V7, taz__w 2
� Signature of citified Well Contractor to
6.Is(are)Ure well(s): C3Permanent or ❑Temporary By signing this form,I hem by cerBfy that the wells)was(were)consfructed in accordance
with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Conduction Standards and that a
7.Is this a repair to an existing well: ❑Yes or B'1Vo copy of this record has been proviakd to the well owner.
If this is a repair,fdl out known well contortion information and explain the nalwe of the
repair render#21 remarks section or on the back of Lltisfmm 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 wyection or non-water supply wells ONLY with the smne construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 7i (ft.) 24a. For AB Wells: Submit this form within 30 days of completion of well
For multiple wells list all dept&s if different(example-3 cQt 200'and 2@100� construction to the following:
10.Static water level below top of casing: (g•) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.Borehole diameter: (un.) 24b.For Infection 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: Rotary construction to the fallovting:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground InjectiotXontrol Prpgram,
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
1 the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chlorine Amount //1 OZ. completion of well construction to the county health department of the county
where constructed-
Form C<W-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013