GW1-2022-10571_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 -FROM R TZ OANES DESCRIP110N
Well Contractor Name
ft ft
NCWC 2028-A ft ft
NC Well Contractor Certification Number is.OUTER CASING for molti ad wdla OR LINER filif bit
FROM TO DIAMETER TFUCICNESS MATERIAL.
Ferguson's Well and Pump, LLC f< " sic el
Company Name 16.INNER CASING OR TU$IlVG. -loo
R FROM . TO DIAMETER 1 THICKNESS I MATERIAL
2.Wen Construction Permit#: 22- 1 U U 1 1 U-1 -1 61. ft ft im
List all applicable weft construction perndts(l.e.Comity,State,Variance,etc.)
ft ft in
3.Well Use(check well use): 17 SCREEN
Water Supply Wefl:- FROM TO DIAMETER SLUE SIZE THICKNESS I MATERIAL
❑Agricultural ❑ paUPublic ft ft in,
❑Geothermal(Heating/Cooling Supply) =ential Water Supply(single) ft ft hL
❑Industrial/Commercial ❑Residential Water Supply(shared) 18 GROUT _
FROM TO MATERIAL EMPLACEM 11TI1WMOD&AMOUNT
01nigation
Non-Water Supply Well: ft 20 Concrete Gravity-Flow
ft ft
❑Monitoring [Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL.PACK e
CEMENT
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLA METHOD
ft fe -
❑Aquifer Test ❑Stomtwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control .
20:DRILLING IAG:attadr adilifimid sheets K
❑Gcuthcrmal(Closed Loop) ❑Tracer FROM To DFSLItEMON color hardness,solyroclt she,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft ft
ft ft
4.Date Well(s)Completed: Well ID# ft ft
Sa.Well Location. ft ft
/ 71/5
rnnnt-Cer r&r.le 7 a l�, ft ft
Facility/OwnerNamc —�? Facility ID#(if applicable) j
ft ft
D IM M An l a,el a t'r ] /l 11sond4idowilke. 2971aft ft
Physical Address,City,and Zip 21.REM ARIrS
WefI-Arsor, ff 9 k6a
County Parcel Identification No.(PIN) ar;17;% +.r
5b.Latitude and Longitude in degtees/minutedseconds or decimal degrees: 22.Certification:
.t{
(if well field,one lattlong is sufficient) Q C�
O�`3Sr7 I W /D /22
Si ofC 5ed Well-co.Coa forI'M Da
6.Is(are)the well(s): EVermanent or ❑Temporary
By signing this form,I hereby certify that the well(s)was(were)consbucted in accordance
with 15A NCAC 02C.0100 or 15A NC,4C 02C.0200 Wdl Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 2KO copy of this record has been provi&d to the well owner.
lfthis is a repair,fill out brown well contraction infornratlon and explain the nature ofthe
repair wukr#21 remarks 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 of wells constructed: construction details. You may also attach additional pages if accessary.
For multiple bgection or non-water supply wells OAZY with the same conatrac6ar you can
submit onefom . SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 7(�S (B) 24a. For All Wells: Submit this form Nvithin 30 days of completion of well
For mtdhple wells list all depths tf dtfferrnt(-w*e-3Q200'and 2 100') Construction to the tolloming:
10.Static water level below top of casing: 510
(ft) Division of Water Quality,Information Processing Unit,
If water level is above casing,are"+" 1617 Marl Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. _ (in.) 24b.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
1L Well construction cable, method: Rotary construction to the following.:
(i.e.auger,rotary,cable,direct push,ere.)
Division of Water Quality,Underground Injectiolt Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
Blowing-Rige. or Water uouy&Iniection Wells: In addition to sea
13a.Yield(gpm) Method of test: 24 F Wt S l ding the form to
the address(es) above, also submit one copy of this form within 30 days of
-13b.Disinfection type: Chlorine Amount: It 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