GW1-2022-10532_Well Construction - GW1_20221121

W L+LL 1-41JIN J 1 RU 1.11UIN KLLUKU For Internal Use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information:
Bobby W. Potts la WAIMR.uiNES
FROM TO Z DESCRIPTION
Well Contractor Name ft ft
NCWC 2028-A ft ft f
NC Well Contractor CatificationNumber IS.OUTER CASING ormcttieasedwells ORLINER d ble
FROM TO DL►?.WM TIUCKNES4 MATERIAL
Ferguson's Well and Pump, LLC ft ft f i" bd2l Acspuqv
Company Name 16.INNER CASING OR TUBING. anQea
AO� (� ^ FROM TO DIAMETER TFUCKNESS MATERIAL
2 Well Construction Permit#: C•l/ ft ft in
List all applicable well c—ft-tion pentdts(le.County,Stage,Variartce,etc.)
ft ft in.
3.Well Use(check well use): 17,SCREEN
Water Supply Well: FROM To DIAMETER' SLOT SM IMCKNFSS I MATERIAL
❑Agricultural ❑ rpaUPublic ft ft in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) fr ft
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT _
FROM TO MATERIAL DeLACFMIM METHOD a AMOUNT
❑hri ation r 0 ft 20 `L Concrete Gravity-Flow
Non-Water Supply Well: - ft ft
❑Monitoring ❑Recovery
Injection Well: & ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK e
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL nWLACEMZNTr.WMODft
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control
DRILLING LOG:attadi addituioai sheets if
❑Geuthcnnal(Clused Loup) ❑Tracer FROM To DFSL211MON color,hardnew soilfroclt etc
❑Geothermal(HeatingACooling Return) ❑Other(explain under#121 Remarks) O ft 70 ft
ft �
4.Date Well(s)Completed: Well ID# ft ft
120
Sa.Well Location: 121)R ft c
e r,4- Yla ft fE
Facilrty/Owner$iame + Facility M#(if applicable)n ft ft :i _ Q
ja /
�dt Or f , '���2 �7 ft ftt7(.1 ,'� i/
Physical
j� Address.City,and p 2L REhtARES
l��l.tr�l'nv►�(�a g to A 3 q�l�y nH
County Parcel Identification No.(PIN)
Sh.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.6 do :
(ifwcfl field,one laMong is suffi31� cient) ry (/
A D
0�� � S' N �4 2 �S 1/ ��fZ 't W Sigffi[ure of Well for S
6.Is(are)the well(s):4ve—ent or ❑Temporary
By signing this form,I hereby cemfy that the weA(s)was(were)eonsdueted in accotrkaree
/ with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well ComIrtw ion Standards and that a
7.Is this a repair to an existing well: ❑Yes or Oqo copy of this record has been prowabd to the well owner.
If this is a repair,fell out known well construction nfbnnalion and cwlam the nature of the
repair tinder#21 remmks section or on the back of thisforrtm 23.Site diagmut 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: I construction details. You may also attach additional pages if necessary.
For multiple byectron or not-water supply wells ONLY with the same construction you can
subnct ate form SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 114qS (B,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list aU depths ifdfferent("mnple-3 O''�and 2@100') construction to the following:
10.Static water level below top of casing: J (ft) Division of Water Quality;Information Processing Unit,
Ifwater level is above casing,me"+" 1617 Matz 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 four within 30 days of completion of well
12.Well construction method: ry construction to the following:
(i.e.auger,rotary,cab lc,direct push,etc.)
Dhision of Water Quality,Under
ground Injecting Control RTgram,
FOR WATER SUPPLY WELLS ONLY: 1636 Marl Service Center,Raleigh,NC 27699-1636
i
13a.Yield(gpm) Method of test: Blowing-Rig 24c.For Water Supply&Injection Wells: 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: Q 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
- t