GW1-2022-06324_Well Construction - GW1_20220705

W LLL UtENNIKU U 1'10IN RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts FROM
FROM TO I DFSCRIYrfON
Well Contractor Name ft O ft
NCWC 2028-A t ft P .ft
NC Well Contractor Certification Number 15.ODTERCASING(for wells)ORUNERif bje
FROM TO DIAMETER TfUCENE44 MATIERIAL
Ferguson's Well and Pump, LLC ft ft r�s ;j" I u I, (/c 2/
Company Name 16.INNER CASING OR TUBING;frauffimpma Aawdjwnp
r
A / FROM TO DIAMETER TR7r kWEt44 MATERIAL
IWell Construction Permit#: b a/_ �)U(p ft ft in
List all applicable well construction permits#e.County,State,Variance,etc.)
ft ft in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM To DIAMETER SLOT SPLE TIRCKNFM MATERIAL
❑Agricultural ❑ ' ipa]/Public ft & m
❑Geothermal(Heating/Cooling Supply) lential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) ill.GROi1T.... _
7f,
TO MATERIAL, EMPLACEMENT METHOD AMOUNT
on- anon 20 fr Concrete Gravity-Flow
Flow
Non-Water Supply Well: tY"
ft
❑Monitoring ❑Recovery
Injection Well: ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK e
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL T maLACEMENTitwmODft �
❑Aquifer Test ❑Stormwater Drainage
ft❑Experimental Technology ❑Subsidence Control ft /
2tL DRII.LING Lt)G attas3i ad&tiiroal sheets if
❑Geothermal(Closed Luup) ❑Trara:r FROM To DFSC dMON color,hardness,sorUroclt etc
❑Geothermal(lleatin Coolin Return ❑Other(explain under 421 Remarks) ('' ft It
// ft 55 ft 4.Date Well(s)Completed: V / Well ID# S.S ft
Sa.Well Location:
ft V5 fte-
/ r S !h C aL cLl C. ft ft
r Faci(ityi&ner.Name Facility M4(if applicable) ft ft �
ft ft - t _g : q ­J
Physical Address,City,aAd Zip 2L RE113AR1 N -
Cqunty Parcel Identifcation No.(PIN) �- hLIMA
56.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one latAong is sufficient)
3/%g?f W
Si ed W 1 n
6.Is(are)the weil(a): errnaneat or ❑Temporary By mgrmig this form,I here by certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an esistmg well: ❑Yes or o copy of this record has been prov!&d to the well owner.
If this is a repair,fill out brown well consbuctionlrtfomtation and erplaur the native ofthe
repair raider#21 rerrmks section or on the bade bf this fomi. 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 byection or non-water supply wells ONLY with the same corssbnctlott,you cars
submit oneforn SUBMITTAL INSTUCTIONS
t
9.Total well depth below land surface: (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if drffenmt(esmnple-3(a 200'and 2@100 construction to the follott'ing:
10.Static water level below top of casing: A 0 00 Division of Water Quality,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Matt Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (in-) 24b.For Injection 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 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,Raleigh,NC 27699-1636
13a.Yield(pm) Method of test: Blowing-Rig 24c.For Water Sunnly&Injection Wells: In addition to sending the.form to
the addresses) 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.
Form G W-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013