GW1-2022-10622_Well Construction - GW1_20221122

WLr+LL 1LV1N61KUl 11(XN KLUUKU For Infernal Use ONLY:
This form can be used foi single or multiple wells
1.Well Contractor Information:
Bobby W. Potts FROM� R To DESCRIPTION
Well Contractor Name & �O ft I'
NCWC 2028-A ft c2 ft f i
NC Well Contractor Certification Number 15:OUTERCASING formulticmed.1wve s ORI.INSR d 61e
FROM TO fD .tu-": 7MCE ESE ' MATERIAL
Ferguson's Well and Pump, LLC Q ft fS'� S VCS 2/
Company Name 16.INNER CASING OR-TUBIlVG: " dosed-lop
a s�J - FROM TO DIAMETER. IMCKNESS MATERIAL
�2.Well Construction Permit#: ft ft 1 in.
List all applicable well construction pern its(t.e.County,State,?rarimacg etc.)
ft ft in.
3.Well Use(check well use):
Water Supply Well:' PROM - To DIAMETER SLOT SIZE TMCKNFS3 MATERIAL
❑Agricultural ❑Muni " blic it ft
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(Sin*)h t ft ft in '
❑lndustriaUCommercial ❑Residential Water Supply(shared) 1&GROUT
❑Irri ation
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
_Non-Water Supply Well: 0fi: 20 ft Concrete Gravity-Flow
❑Monitoring ❑Recovery ft ft
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19..SAND/G"VIL PACK. e
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL I EMPLACEM0T T11ETHODft �
❑Aquifer Test ❑Stomtwate.r Drainage ft ft `
❑Experimental Technology ❑Subsidence Control r.
20.":DRIL;II3GZOG s;ttarb'addit?aaalsheets if
❑GCuthermal(Clused Ltwp) ❑Tra.= FROM TO DESCRIMON or hardness,sdlhu t etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft ® .ft
ft S ft
4.Date Well(s)Completed: well ID# it it '
Sa.Well Location: ftGM W
ft C
FacilitylbtvnerName acility ID#(if applicable) ft ft i ° ti m° 9 }—I.vf ~
_E421 W1r00A /?d_ ` lthn 28 7Lo/ ft ft NOV 2 L 2022
Physical Address,City,and Zip 2.L REMARKS.
'U2 5669 367G/ Ir>4cc:•� ,a,�,r�r . M 1 net
C*y_ Parcel Identification No.(PIN)
56 Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 CertiScation:
(ifwell field,one lattlong is sufficient)
3s 3 t5lr /p ' N �
Signature o ed W I Contras r . D
6.Is(are)the weil(s): ermanent or ❑Temporary $y sipft this f=4 1 hereby cer*that the wells)was(were)constructed in accon*xce
with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or BNo copy 0f this record has been pmvi&d to Abe well owner.
Ifffas is a repak fill out known well construction afonnalion and ezpZWn the nature ofthe
repair under#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
8.Number of webs constructed: construction details. You may also attach additional pages if necessary.
For multiple hyecum or non-water supply wells ONLY with the same consftedon,you can
submit oneforn SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 7�� (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple well;list all depths ifd0erwd,("wnple-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: VO (ft) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Mad Service Center,Raleigh,NC 27699-1617
I '
11.Borehole diameter. "` (in.) 24b.For Iniecdon 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 coustruction.method: Rotary construction to the following:.
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,U I dergr ound InjecdolkControl Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service C6 er,Raleigh,NC 27699-1636
13a Yield(gpm) Method of test: Blowing-Rig 24c.For Water Supply&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
,13b.Disinfection type: Chlorine Amount ,Sa QZ, completion of well construction to'the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013