GW1-2022-10594_Well Construction - GW1_20221122

W LLL LU1Nb'1 KU 1;11UiN-KLt'WKV For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts 14.WAXM TO'
FROM DMSCRiYITON
Well Contractor Name ft /y i1 ft
NCWC 2028 A ft ft
NC Well Contractor Certification Number 15.OUTER CASING(for maWcased wells)ORLIPaR rif bie
FROM I I DIAMETER i I IMCBNM I MATERIAL
Ferguson's Well and Pump, LLC ft 0 ft r w
Company Name 16.INNER CASING OR TUB111G.4modiersnal cluxed4otml
^ FROM TO DIAMETER IMCKNM4S MATERIAL
IWell Construction Permit#: . 2 Z d 1 1 tt ft in
List all applicable well cmir won permits(i.e.Cotmty,State,i'arrmreg etc.)
ft ft in
3.Well Use(check well use): 17 SCREIIat
Water Supply Well: FROM TO DIAMETER . SLOT SIZE I TMCKNMS3 MATERIAL
❑Agricultural GN�'�m a�a�l/Public ft ft in
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft tR
❑Industrial/Commercial ❑Residential Water Supply(shared) IL GROUT _
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Ohrigation 0 rt 20 ft Concrete Gravity-Flow
Non-Water Supply Well:
ft ft
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19 SAND/GIX4VIL"PACK or spolicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier. FROM TO s MATERW EMPLACEMEN METHOD
ft ft
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control
.21I DRILLING LOG:attmfi addifinta Ahceis if M
❑Geothermal(Clusrd Luup) ❑Tracer FROM TO DESCRIPTION cotes hardn sofUrock etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 1 Ott D ft
so ft ft. s
4.Date Well(s)Completed: ���Well lD# 170 ft, �O ft /�
Sa.Well ft �- ft t
c r
CJ �r1 b e.1 5 _ ft ft
Facility/0ttimer tame Facility ID#(if applicable) ft. ft
t,
"l tJ(ir—niikssk " IACe f-ajadA WL ft ft .,
Physical Address,City,and 'Zap 2L REMARKS
-5y„I uORh►to �R 7A -7-2 -ton
County Parcel Identification No.(PW)
1(hvi ix:c3�.'..
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 Certiffcation
(ifwcll field,one lat/long is sufficient) •
35, �5,�1�t �l/ tt N 53'X0 3Y'3/ (zyfY " w z
sigmNre of fied ell Co tractor
6.Is(are)the well(,): Cwermanent or ❑Temporary
By sigrmig this form,I hereby certify that the weA(s)was(were)conrirmied m accordaree
�� with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Consirmfim Standards and that a
7.Is this a repair to an existing well: ❑Yes or lawn copy of this record has been prov/and to die well owner.
If this is a repair,fill om biown well cembuction biformtation and eV1=the natti a of the
repair wider#21 r marb section or on the back of dwform 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 byecam onion-watersmpply wells ONLY with the same corisbacrian you cam
mbmrit are form SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: �/e (tit) 24. For All Wells: Submit this form within 30 days of completion of well
For mwlople wells list all depths if Ji enmt(exmnple-3©200 Q100') construction to the following:
I
10.Static water level below top of casing: 00 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
Rota above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ry construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Qualttp,Underground Injectiop Control Prggram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield m Blowing-Rig24c.For Water Sannly&Iniectioaa Wells: In addition to sending the form to
(gp ) p1 Method of test: �
the address(es) above, also submit one copy of this form within 30 days of
13b Disinfection type: Chlorine Amount 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