GW1-2022-10539_Well Construction - GW1_20221121

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts ltt FROM T WATER u0 T I DESCRIP170N
Well Contractor Name ft / ft
NCWC 2028-A ft ( ft
NC Well Contractor Certification Number ' I&OUTER CASING(for mulfi-caedwefls ORLINBR d bk
FROM TO DIAMETER nuCE3 rrec MAy�AI,
Ferguson's Well and Pump, LLC 0 ft. -37 ft t KS Z
Company Name 16.1NNER GORTURINGimeodpwnialdosed
FROM I TO I DIAMETER I THICKNESS I MATERIAL
2.Well Construction Permit#: 01 Oa l• U V Q ft it. in
List all applicable well construction pern us(ce.County,State,Uarrmice etc.
ft ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO I DIAMETER I SLOT SIZE I THICKNFSS I MATERIAL
ft is
❑Agricultural ❑ cr
❑G paUPublic ft
eothermal(Heating/Cooling Supply) QResidential Water Supply(single) h• ft m.
❑lndusttial/Commercial ❑Residential Water Supply(shared) "I GROAT _
alailion
FROM i MATERIAL MATER EMPLACEMENT NrMOD dl AMOUNT
Non-Water Supply Well: 0 ft 20 fr• Concrete Gravity-Flow
❑Monitoring ❑Recovery ft. ft
Injection Well: ft ft
[]Aquifer Recharge ❑Groundwater Remediatiou 19.SAND/GRAVEL PACIs
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO I MATERIAL EMPLACEMENTMEMODft � -
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑ ft ft
Subsidence Control P.
Z4.DRII3:ING LOG.athdradditiooal a6e&K
Cl Geothermal(Closed Loup) ❑Tracer FROM TO DESCIUMON color hardoem soiLkocle 0196 ffaln die,eta
❑Geothermal(Heatingrooling Return) ❑Other(explain under#21 Remarks) () & ft
ft 4.Date Well(s)Completed: Well ID# d ft.
ft
C C
Sa.WeIILocation: ft ft W C
l 5n,5hr •c 4 l'0 ft &
Facilityb6crNamc Facility M4(if applicable) P q
11a Ice.-06l WrIS4 -Le- sfer 987q8 ft ft
Physical Address,City,and Zip
21.REMARKS
'I ur$�
CQUnty Parcel Identification No.(PIN) CrA Q1330G
51L Latitude and Longitude in degrees/minutes/smonds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
?S_0361 y?,/yY ' N -9—A— � t ,r Zk 5o ' ' W 4411
Signatnie f fied well Contrac Datt
6.Is(are)the well(s): ermanent or ❑Temporary By fo„n 1 hereby cemjy that the weA(s)was(were)carsysucted in accordm�ce
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Constrmclion Standards and that a
7.Is this a repair to an existing well: ❑Yes or o copy of das record has been praw&d to the well owner.
If this is a repair,fill out brown well conduction bfom ation and eViam the nature of the
repair urukr#21 ronmb 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
8.Number of wells constructed: l construction details. You may also attach additional pages if necessary.
For multiple byeenan or non-water supply wells ONLY with the same eonsaucnon,you can
submit one fours SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: %�S ap 24a. For All Wells: Submit tiffs form within 30 days of completion of well
For multiple wells list all depths if�ervd("xnple-3@2200'andn2@I00� construction to the following:
10.Static water level below top of casing: �!/ (ft) Division of W ales Quality;Information Processing Unit,
If water level is above easu g,use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
i
11.Borehole diameter. (in.) 241b.For Iniection 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 constriction method: Rotary construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) i
Division of Water Quality,Underground Injectio&Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cent,Raleigh,NC 27699-16M
13a.Yield(gpm) �� Method of test BloWing-Rig 24c.For Water Snnn1F&lWaction 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: ClliOnne Amount: s'S OZ, completion of well construction to the county health department of the county
where constructed-
Form OW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013