GW1-2022-10540_Well Construction - GW1_20221121

WELL LIJNNIRUC 11ON RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts lawATERzoNEs
FROM TO DESCRIPTION
Well Coritractor Name ft it.
NCWC 2028-A & ft 1
NC Well Contractor Certification Number IS.OUTERCASING far wdls ORUNER d bk
FROM TO DIAMETER TIDCKNFSS MATERIAL
Ferguson's Well and Pump, LLC rt ft f , ,;>`
AS- VWso,1921
Company Name 16.1NNER ING OR TUMNG.Im6admirm2i awwdJu%rA
/�
FROM TO DIAm T R1 'mile -m MATERIA
d
2.Well Construction Permit#: ' O070.- y U ,3q J ft in
List all cable well construction is i.e.C
applicable penal ( Dimly,Stote,'Vanmrce,etc.) ft ft f in
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DL MITER, SLOT SIZE TIDCENMSS MATERL41
❑Agricultural ❑ pal/Public ft ft in
❑Geothermal(Heating/Cooling Supply) ential Water Supply(single) '� ft ft in.
01ndustrial/Commercial ❑Residential Water Supply(shared) 18.tRiOET
FROM TO MATERIAL EMPLACEMFJST 1kM"MOD a AMOUNT
❑Inn aon fc .,Gravity-Flow
Concrete
Non-Water Supply Well: 0
❑Monitoring ❑Recovery ft ft
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND I..VELPACK e
EMPLACEMEN f
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO I MATERIAL MEI'EIODtt �
❑Aquifer Test ❑Storm Dra
inage ainage ft ft
❑Experimental Technology ❑Subsidence Control i t
2A:DRII.LII!IG LOG:atbuh addidamil Aheets ff
❑Geuthennal(Cluscl Luup) ❑Traces• FROM To DL%3dp'1T0N cdor harm soi0foctt etc
❑Geothermal(Heating/Cooling Return) Other(explain under 421 Remarks) a ft. 0 .ft Q 1
ro
4.Date Well(s)Completed: ��Well ED# v h ft �e
70 ft ft
rdkg
52.Well Location:
-75 ft- S ft
111 t l lllrw,= Fuu ft ft
Faccility/damer.Namc►[� ,./ Facility ID#(iif applicable) R ft J'ram
L�tA b Or 0✓e F/?m y L u-i oZ ig-/3 0 ft ft
Physical Address,City,and Zip / 2L REMARKS
Comity Pareel Identification No.(PIN) (hvi
56.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one IatAong is sufficient) 22•Certlfcation:
Signature o Cerfified Well niractor to
6.Is(are)the wen(s): Zfermantnt or ❑Temporary
By stVung this form,I hereby certify that the well(s)was(were)constructed in accordance
�,� with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Wdl Conrductiorr Standards and that a
7.Is this a repair to an existing well: ❑Yes or J�`to copy of this record has been provi&d to the well owner.
If this is a repair,fill out brown well construction brjonmation and eiplainn the nurture of the 1
repair under#21 remarks section or on the back of this form. 23.Slte diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of webs constructed: f construction details. You may also attach additional pages if necessary.
For maniple irgection or non-water supply wells ONLY with the same eonsbue6an you can
saber a+eform SUBMITTAL INST UCPIONS
r
9.Total well depth below land surface: Sos (g) 24a. For All Wells: Submit this form within 30 days of completion of well
For muntple wells list all depths if anfferent(esanple-3@200'and 2Qa 100D construction to the following:
10.Static water level below top of casing: ��7 (K) 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. _ (m.) 24b.For Infection 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
17.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injectiog Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) S Method of test: Blowing-Rig 24c.For Water Suonly&Injection Wells: In addition to sending the.form to
the address(es) above, also submit one copy of this form within 30 days of
136 Disinfection type: Chlorine Mount: j OZ, completion of well construction to the county health department of the county
fLt where constructed
Form OW-1 North Carolina Department of Enviroament and Natural Resources—Division of Water Quality Revised Jan.2013