GW1-2022-06327_Well Construction - GW1_20220705

WELL UOINS1'RU C'1'lON-RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts FItoMNTEIZ TO I DESCRIPTION
Well Contractor Name ft V/J ft
D'
NCWC 2028-A ft &
NC Well Contractor Certification Number 15:OUTERCASING fotmdd-caied.,was ORIMER if 6b
Ferguson's Well and Pump, LLC FROM ft TO nLtM>rrER� TIC cr �� MATERIAL
� 2
Company Name 16.INNER CASING OR G.fffeodrermd clused4000l
/ FROM TTO DL4NMTF.R- I TIDCSNESS I MATERIAL
2.Well Construction Permit#: !2 O� � ft ft, in.
List all applicable well construction permils(:'e.County,Slate,Var-lmrce,etc.)
ft. ft in.
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FRaM TO DLIMETER SLOT SIZE TFHCENFSS MATERL41
❑Agricultural ❑ pa]/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) El esidetntial Water Supply(single) ft ft m
❑lndustrial/Commercial ❑Residential Water Supply(shared) It,GROUT
❑Irri ation
FROM TO MATERIAL. EMPLACEMEWMETHOD&AMO
� UNT
Non-Water Supply Well: ft 20 & Concrete Gravity-Flow
❑Monitoring ❑Recovery ft ft
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK Cif avdicmc)
❑Agtrifer Storage and Recovery ❑Salinity Banier FROM To MATERIAL EMPLACEMENTAETHOD
ft R
❑Aquifer Test ❑Stormwater Drainage
ft ft
❑Experimental Technology ❑Subsidence Control '
20.DRILLII!lG LOG ittadi addiLluual abeets if /
❑Geothermal(Closed Loup) ❑Trauer FROM To DECRIPTION or 6ardn solUrogi Aze,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 1 0 ft t 0
-ft ft
4.Date Well(s)Completed: Well �-ID# ft ft
Sa.Well Location: 1/06
ft ft
ft ft
Facility%(Ynmerlame Facility ID#(if applicable) R ft
~ -
IQ3 O gr_(:aew\1A ^. _ 6(/ r2AA042 ft t
Physical Address,City,and Zip
2LREMARKS 7C,r:r�:�+ti'1 rc C.•D�"<" 1�R11.
�11Crn)be
v VQ% if}L7V.h
County Parcel IdentiScationNo.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Ce tin:
(if well field,one lat/long is sufficient)
3� yy Le 7 57o�_W > -
Signature o tied Well ChOdGr afe
6.Is(are)the well(s): 21rrrmanent or ❑Temporary
B3'sig»irrg this fort I hereby cer(ify 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 existing well: ❑Yes or lx copy of this record has been provikd to the well owner.
If this is a repair,full out known well construction information and esplabn the nature of the
repair under#21 remarks section or on the back of fimform 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 hyectron or non-water supply wells ONLY with the same consbtction you can
submit a nefo?m / SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 36S (fL) 24. For All Wells: Submit this form within 30 days of completion of well
For mahiple wells list all depths tf different(exornple-3@200'and 2 100 construction to the following:
10.Static water level below top of casing: 20 A) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Matt Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. (in.) 24b.For injection WeRv_ 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 fulloming:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injecties Control Pwgram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
Blowing—Rig2c. or Water Surely&Injection Wells: In addition to see
13a.Yield(gpm) � Method of test: 4 F W ding the form to
the address(es) 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 Emdronment and Natural Resources-Division of Water Quality Revised Jan.2013