GW1-2022-06361_Well Construction - GW1_20220705

WELL LL UOIN 1RU C;IION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts 14 WATERZO
FROM TO DFSCR=ON
Well Contactor Name ft R
NCWC 2028-A ft ft
NC Well Contractor Certification Number 15.OUTERCASING formniti-casedvells ORLINERR if ble
FROM TO I I THIr•rrraM MATERAL
Ferguson's Well and Pump, LLC ft Sri
r 1119C Company Name 16.INNER CASING OR TUBING; eased-lain
t FROM TO I DIAMETER I THI1-aM I MATERIAL
2.Well Construction Permit#: S W 1 , h.2k C4,S ft K in
List all applicable well construction permits(i.e.County,State,V_ia ce,etc.)- ft ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SM TMCENM MATERAL
❑Agricultural ❑M ft ft in
cipa]/Public
❑Geothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft ur.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT. _
FROM TO MATERIAL nee ACEMENTMETHOD&AMOUNT
Non-Water[]Irrigation
Supply Well: 0 ft 20 & Concrete Gravity-Flow
it ft
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK. cafe
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft r ,
❑Aquifer Test ❑Stormwater Drainage
ft ft
❑Experimental Technology ❑Subsidence Control m r
2tL"DRILLING LOG:attach iddititail sheets if
❑Geuthezmal(Closed Luup) ❑Traces FROM I TO DFS(.'RIP'ITON color,hardness,solUrock 92 etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft ft
ft. ft �
4.Date Well(s)Completed: Well ID# ft ft
Sa.Well Location: ft ft j C
�7 3ci L LC- ft. ft r
Facilitylowner•Name Facility ID#(if applicable) ft ft
"l 5(0 14 l C.4c t,( Lt)O I"' RLtAb,rcy J 4, -it ft ft
Physical Address,City,and Zi 21.REMARKS
Rs&1)nwfmrJ ' (o y 14 l S O
Cpanty Parcel Identification No.(PIN) a rfi;;in I'
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
.440 1 r N � ?,6 r _W
Signature of C ed Well-Con for
6.Is(are)the we' ( rmanent or ❑Temporary
By sigrnimg t fore,I hereby 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 existing well: ❑Yes or No copy of this record has been provi&d to the well owner.
If this is a repair,fill out known well construction Wornnalion and eaplain the nature of the
repair under#21 remarks section or on the back of this form. 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 nznlhple ugection or non-water supply wells ONLY with the sane construdian,you can
submit one form SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: �2 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For nalttple wells list all depths if different(example-3(200'and 2 a100') construction to the following:
10.Static water level below top of casing: J 0 (ft) 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
Rotary above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injectiog Control Pwgram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield m Blowing-Rig24c.For Water Suns &Iniection Wells: In addition to see the form to
(gp ) Method of test: the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chlorine Amount: 7 OZ. completion of well construction to the county health department of the county
where constructed_
Form CAW-1 - North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013