GW1-2022-10569_Well Construction - GW1_20221121

W hLL UUINSIRU UTIUN RL+CORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts U WATE"ZONES
FROM TO DESCREMON
Well ConUactor Name ft ) ft
NCWC 2028-A ft ft j
' 15-9MRCASING Fever aredwells OR LINER d ble
NC Well Contractor Certification Number ,
FROM TO DIAMETER nuc3gai4S MATERIAL
Ferguson's Well and Pump, LLC rt jW ft- ;R t L%
Company Name 16.INNER CASING OR G. dosed
It /� FROM TO ETER DIAM THIC%NF84 MATERIAL
2 Well Construction Permit#: O( y ft. ft, in.
List all applicable well construction permis rise Colony,State,*Varimice,etc.)
fL ft in.
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMECF.R SLOT SIZE I 1MCItPI M I MATERIAL
❑ cultural ft ft m
A!� ❑ cipaUPublic
❑Geothermal(Heating/Cooling Supply) OW
Water Supply(single)1 r ft ft in
❑Industrial/Commercial ❑Residential Water Supply(shared) 11 GROUT
FROM TO MATERIAL F.De1 ACEMEN`rN=OD a AMOUNT
Non-Water Supply
Well:
0 ft 20 ft Concrete Gravity-Flow
❑Monitoring ❑Recovery
ft. ft
Injection Well: ft- ft
❑Aquifer Recharge ❑Groundwater Remediation 19 SAND/G9AVEL PACK.fif
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To T MATERIAL FMPLACEMINT MEMOD
R fit
❑Aquifer Test ❑Stormwater Drainageft
ft
❑Experimental Technology ❑Subsidence Control o
211 DRILLING LOG-4ttmh additiiaoal H
❑Geutht=al(Closed Luop) ❑Tracer FROM To DFSCRiPTION color hula sowUrocQ etc
❑Geothermal(Heating/Cooling Return) ❑Other( lain under#21 Remarks) 1 011-TV
t a ft
ft
4.Date Wells)Completed: � i/./dtT Well ID# ) ft. t` V .
-� 00ft ftJiv
5a./W�eR Location: Vd ft s ft t �,
ft ft
Facility/Owner,Name Facility 1D#(if applicable) R R "� t
27j (4cr)rug (AJOW 14enArs,. hVit(f �Vna- ft. ft NOV -
Physical Address,City,an 'p 2L REMARI{S
County Parcel Identification No.(PIN) F=
Ir►r ra!?
5b.Latitude and Longitude in degreeshaunutes/seconds or decimal degrees:
(ifwell field,one lat/long is sufficient) d� 22.Certification:
t7 sett t/ ` `
av
N �y7 ��r. `7`�t/t1 W
Sigffit= CeyN cd Well ntrac r m
ti.Is(are)the well(s): ermanent or ❑Temporary
By sl9m g this form,I hereby cer*that the weA(s)was(were)constructed in accordance
with I5A NCAC 02C.0100 or ISANCAC 02C.0200 Wdl Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or @No copy of this record has been provi&d to the well owner.
If this is a repair,fill out brown well contraction bfommlion and explain the nanne of the
repair under#21 ranarks section or on the barb 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 of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple irgecuon or non-wazer supply wells ONLY with the sm w construction,you can
submidt�f� 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 rmrldple wells ltat all depdu if different(example-3(d 200'and 2@100') construction to the following:
10.Static water level below top of casing: (t) Division of Water Quality,Information Processing Unit,
If water level is above easing,uve"+" 1617 Marl 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 form within 30 days of completion of well
12.Well construction method: Rotary construction to the fallowing:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injectiog Control Prpgram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield m RI 24c.For Water Suonly&Injection Wells: in addition to see
(gp ) Cl- Method of test: Blowing-Rig g- g ding the form to
the address(es) above, also submit one copy of this form within 30 days of
136 Disinfection type:• Chlorine fin OZ. completion of well construction to the county health department of the'county
Amount where constructed.
I
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013