GW1-2022-10565_Well Construction - GW1_20221121

This form can be used for single or multiple wells I
1.Well Contractor Information:
Bobby W. Potts FRO TER TzoNFs DESCRIPTION
Well Contractor Name ft 90 ft
NCWC 2028-A ft ft
NC Well Contractor Certification Number 15.OUTERCA5ING(for mul4-catodwe[ OR LINER Of ble
FROM I TO I DL►?JE= TFiICIMM MATERIAL
Ferguson's Well and Pump, LLC 0 ft ft C 21
Company Name 16.INNER CASING OR G. ' dused-i
r FROM TO DWA TER THICKNESS MATERIAL
L Well Construction Permit$: t C_� — U L ft ft in.
List all applicable well construction permits(i.e.County,State,Variance,etc.)
ft ft in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE TEUCENM3 MATERUL
ft ft in
❑Agricultural ❑ tpal/Public
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft in
❑Industnal/Commercial ❑Residential Water Supply(shared) M GROUT FROM I TO MATERIAL DeJ ACEMENT MJiTHOD&AMOUNf
0 rt 20 rL Concrete Gravity-Flow
Non-Water Supply Well:
it ft
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK Of applicable)
FROM TO MATERIAL I724PLACEMFIIT Ag I IiOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft:
❑Aquifer Test ❑Stormwater Drainage
ft ft
❑Experimental Technology ❑Subsidence Control 1A DRILLING LOG.attsdi addil onalaheeCsif /
❑Meuthwinal(Cluscd Luup) ❑Tracer FROM TO DF0dMON color,hardness,soiUrocQ d2e,etc
❑Geothermal(Heatin Coolin Return ❑Other(explain under 421 Remarks) 6ft ft
ft _5 ft
4.Date Well(s)Completed: fv �� Well ID#
S ft 25 ft
5a Well Location: 5 ft & Q W,-:76 I
� hn t hrula,'LS M ft
Fatuity/Owner Name Facility 1D#(if applicable) ft ft
611 tvi&n 61(c 'eJ emVol? ae 716 ft ft ,h
Physical Address City,and Zip 21.REMAM
�aT,y�a $64 ci- N! -ia.4 022
County Parcel Identification No.(PIN)
t
fm
5b.Latitude and Longitude m degrees/minutes/seconds or decimal degrees: 22.Certification: irti0f�. y1,> j ^
(if well field,one lat/long is sufficient) r
N C '
W� N 7 t�'�t tW Si lure of ed Well Contractor Da
6.Is(are)the well(s): Permanent or ❑Temporary By signing this form,I hereby certify that the weA(s)was(were)conshueted in accordance
0(.-" with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Stands&and that a
7.Is this a repair to an existing well: ❑Yes or 0(. copy of this record has been proviabd to the well owner.
If this is a repair,fill out known well construction irrfor nation and e:plaw the nature of the
repair under#21 ronmlcs 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 ofwells constructed: construction details. You may also attach additional pages if necessary.
For multiple opection or non-water supply wells ONLY with the sane constnu tun,you can
submit oneform SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: y� (ft) 24a. For All Wells: Submit this form Avithin 30 days of completion of well
For nwinple wells list all depths ifdifferent(exanple-3Q200'and 2@100� construction to the following:
10.Static water level below top of casing: 20 (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. (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
4 Rota above, also submit a copy of this form within 30 days of completion of well
12.Well construction method Rotary construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Prpgram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service jcenter,Raleigh,NC 27699-16M
r. _
Blowing-Rig 24c.For Water Supply&Infection Wells: In addition to sending the form to
13a Yield(gpm) Method of test: the address(es) above, also submit one copy of this form within 30 days of
136.Disinfection type: ChlOnne Amount �� OZ. where constructed.completion of well construction!to the county health department of the county
4
Form CAW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan:2013