GW1-2022-10626_Well Construction - GW1_20221122

W.LLL UU1V.S'Y'KUC;' 1ON RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts aR M� TzorlES DFSCR MON
Well Contractor Name ft ft
NCWC 2028-A ft ft � I
NC Well Contractor Certification Number 15:0UTEA9ASING formWficased.,WQe% ORLINER if ble
FROM TO DTeturrrrm THIt•rrnrncc MATERIAL,
Ferguson's Well and Pump, LLC 69 ft Z in ,as
Company Name lti INNER GAS G OR TUBING: used-1
^ FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 0 a a J ft ft in.
List all applicable well construction permits f.e.County,State,Vzo lmwe,etc.)
ft ft in
3.Well Use(check well use): 17.5GREEN
Water Supply Well: FROM TO DIAMETER I SLOT SIZE I THICKNESS MATERL4L
❑Agricultural ❑ tpal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft in
❑Industrial/Commercial ❑Residential Water Supply(shared) 11L GROUT
FROM TO MATERIAL MWLACEly ENTItEMOD AMOUNT
Nonn--Wate
❑ ater$apply Well: 0 rc 20 ft Concrete Gravity-Flow❑Monitoring ❑Recovery ft ft
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK e
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft TO MATERIAL EMPLACEMENT1%WM0D
❑Aquifer Test bStormwater Drainage fc ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG.attadi addifignAsheelsif
❑Geuthetuna!(Clused Luup) ❑Tracer FROM TO DFSLldMONcolor hardness,soiUroclt size,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft ft /►
ft ft l
4.Date Well(s)Completed: Well D3# ft ft
C
Sa well Location: ft ft
�Ar1lC.l .4A)ttlr►Ca./ A /a1 & ft
Facility/Owner Name Facility ID#(if applicable) ft ft J C1,
a 6 l$- gg
1✓l]b OU / X bo oC p 1(o _ fc ft
Physical Address,City,and Zip
2L REMARI{SNOV 2 2 206L
Inil
County Parcel Identification No.(PIN)�v
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat4ong is sufficient)
N2
Signature of Certi Well Contracto Da
6.Is(are)the Well(s): L7Yermanent or ❑TeLuporary By Sze this fom I fib,certify that the well(s)-was(were)constructed in accordance
��� with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Consirwfion Standards and that a
7.Is this a repair to an existing well: ❑Yes or PFO copy of this record has been provukd to the well owner.
If this is a repair,ftQout known well construction information and ezplabn the nature ofthe
repair under#21 r e norks section or on the back of Ats 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 necessaty.
For mulhple oyectton or non-water supply wells ONLY with the sane construction,you can
submit oneform SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 7 0 S (ft,) 24a. For All Wells: Submit this form Avithin 30 days of completion of well
For multiple wells&I all depths if different(4anple-3@200 and 2(100� construction to the following: 1
'
10.Static water level below top of casing: a2 n (ft) Division of Water QuaIlity,Information Processing Unit,
If water level is above casirng,use"+" 1617 Marl Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 40 (in.) 24b.For Iniection Webs: In addition to sending the form to the address in 24a
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 Center,Raleigh,NC 27699-1636
132.Yield(gpm) l Blowing-Rig24c.For Water Supply&Iniectitin.Wells: In addition to sending the.form to 2 Method of test: �
We 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 GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013
I
I