GW1-2022-10525_Well Construction - GW1_20221121

WL•LL LUMIRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts 14 wATERzoNEs
FROM TO I DESCRIPTION
Well Contractor Name ft ft
NCWC 2028-A ft ft
NC Well Contractor Certification Number 15.OUTEA ASING farm�S-eated.weils ORLiN6R d ble
FROM TOI DIAM@TSR SS nuclai MATERIAL
Ferguson's Well and Pump, LLC ft ft r)�S;In 2 S c
Company Name nn ^ —�U, � 16.INNER CASING OR TUBIlVG. tlmed-loo
V da '� a- FROM TO DIAMETER THICKNESS MATERIAL
L Well Construction Permit#: ft ft.
List all applicable well conshvction penuts d.e.County,State,T�artmtee,etc.) ft I in
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNES3 MATERL4L
ft ft in'
❑Agricultural ❑ ipal/Public
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft m
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT
FROM TO MATERIAL EMPLACD 4ENT DtETHOD A AMOUNT
Non-Water Supply Well:
❑ aon 0 rt 20 Concrete Gravity-Flow
❑Monitoring ft ft
❑Recovery
Injection Well: M ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PA l K e
FROM TO MATERIAL ENLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier & ft ,
❑Aquifer Test ❑Stormwater Drainage
ft ft
❑Experimental Technology ❑Subsidence Control r
21L DRILLING LOG:attach addjtaignal meet id
❑Geuthemal(Clused Loup) ❑Tracer FROM To DESCRIPTION color hardness,sontroclt d2e,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 1 ft o ft a k
Qfe
4.Date Wells)Completed: � � � Well ID# ft ft ft ft C
5a.Well Location: ft it t
W
Facility/Ow ft ftner Name Facility ID#(if applicable) ft ft �..
v� /�
.-at --
3� YL.n Q 121a'rn6!t. e! IA.4)eu 1-(tL Q8805 ft ft '
Physical Address,City,and Zip
tags N 4'9 3Wow UrA
County Parcel Identification No.(PIN) O
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwcll field,one lat/long is sufficient)
; Sd363Grf�S�OS't if
N �'�°Zg �� y4'z W -
Sigffiture of fled We Con r D
6.Is(are)the well(s): tdPermanent or ❑Temporary By srrft this forn4 I hereby ce?*that'dw well(s)-was(were)constructed m accordance
with 1 SA NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or o copy of dw record has been provi&d to the well owner.
If this is a repair,fill oat brown well construction hfornration and eWlaet the nature of the
repair under#21 remarks section or on dw back of dusfomc 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 rmdtiple i►gemon or non-water supply wells ONLY with the saute carsbucdon,you can
submit oneform SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: �� (g) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(exmnple-3@200'and 2@100') construction to the fbUovting:
10.Static water level below top of casing: c��_(ft) 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. (ire.) 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 foUo-Ring:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Ptpgram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center;Raleigh,NC 27699-16M
13a.Yield(gpm) 40 Method of test: Blowing-Rig 24c.For Water SuDgh&Injection W1 ells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chlorine Amount: �p OZ. completion of well construction to the county health department of the county
(/ I where constructed-
Form C'W-1 North Carolina Department of Environment and Natural Resources—Division of Water Qualil Revised Jan.2013