GW1-2023-02031_Well Construction - GW1_20230303

WELL UUN STKU CTlON RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts mom R TO T DUMP ION
Well Contractor Name ft ft
NCWC 2028-A ft ft
NC Well Contractor Certification Number 15.OUTER CASING(for mniti-cased.wells ORLINER d able
FROM TO DL?.WM THICKNESS MATERIAL
Ferguson's Well and Pump, LLC ft ItI 4,13t S
Company Name 16.INNER CASING OR TUBING.iffeadierm2l dosed4w
r FROM TO I DIAMETER I THICKNESS I MATERIAL
2.Well Construction Permit#: V a' — 6 b ft ft ;n
List all applicable well construction permits(i.e.Couio,State,Variance,etc.) ft ft in
3.Well Use(check well use): 17,SCREEN
Water Supply Well: FROM To DIAMETER SLOT SUE THICKNESS MATERIAL
❑Agricultural ❑MM/unicipal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) Aresidential Water Supply(single) it ft in
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM I TO MATERIAL EMPLACOM rMETHOD&AMOM
[]Irrigation 0 ft 20 ft Concrete Gravity-Flow
Non-Water Supply Well: ft ft
❑Monitoring ❑Recovery
Injection Well: ft &
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK e
FROM I TO MATERIAL FMPLACEMENT MMOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control
20:DRILLING LOG.ittadi'addifibk l stieetsif
❑Geuthminal(Closed Luup) ❑Tracer FROM TO DESt'REMON color hardness,soilirock si2e,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) 6
ft ft (
ft S ft �
4.Date Well(s)Completed: 4,L 15 Well EM ft ft
Sa.well Location: e C
ft —11 C
�) ,yL_ Vleis 5 NL t I i:Cart ft M
Facility/OwmerNamc Facility 1D#(if applicable)
ft ft
(a k 5000M "bent 1), u c 'AI K Min, a2i 711 ft ft i
Physical Address,City,and Zip -
2L REMARKS MAR 'J
County farce]Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one laMong is sufficient) 22.Certification:
3SC'2 yGl1fyt N _9; A7%YaGttS�� tr w411A9,1' /),
SignAire of Ccrti We] ntractor Date
6.Is(are)the well(s): 20et'mancnt or ❑Temporary By signing this form I hereby certify that the well(s)lwas(were)constructed in accordance
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 L71Va copy of thus record has been prowakd to the well owner.
If this is a repair,fill out known well construction information and explain the native of the
repair under#21 ranarlis 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 necessary.
For multiple agection or non-water supply wells ONLY with the same construction,you can
submit one form SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 7G 5 (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(aranple-3@200'and 2 a@100') construction to the following:
10.Static water level below top of casing: (ft) Division of Water Quality,Information Processing Unit,
If water level is above easing,are"+" 1617 Mail 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
Rotary above, also submit a copy of this form within 30 days of completion of well
11 Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground InjectiaLL Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
Blowing-Rigc. or Water Supply niecton ells: In addition to sending 13a.Yield(gym) Metlrod of test: 24 F Wt S l &I i W ding the form to
the address(es) above, also submit one copy of this form within 30 days of
.13b.Disinfection type: Chlorine Amount: JO oZ. completion of well construction to the county health department of the county
where constructed.
Form CAW-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013