GW1-2023-02034_Well Construction - GW1_20230303

W ll LL CU1V J.1 KU C 11UIV KLCUKU For Internal Use ONLY: '
This form can be used for single or multiple wells
1.Well Contractor Information:
BobbyW. Potts
. FROM TO , DESCRIPTION
Well Contractor Name - ft Q0 ft
NCWC 2028-A - •ft 370 ft .
NC Well Contractor Certification Number 15.OUTER.C.ASINGtformulfkosed.wells)ORLINER(if )
. FROM TO DIAMETER THICKNESS MATERIAL
Ferguson's Well and Pump, LLC 0 ft 70k fc 1v to S in. 7/4//20. VAC SD/L2/
Company Name - 16.INNER CASING OR TUB NG:(Raoot eritu l doeea-loon)
A�� r� FROM TO DIAMETER THICKNESS MATERIAL
2 Well Construction Permit#: O( Qo 56. in.List all applicable well construction permits(ie.County,State, rrance,etc). .
f. ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑ oulhtral ft ft. in.
❑ pal/Public
OGeotheamal(Heating/Cooling Supply) . Residential Water Supply(single) ft ft is - ,
❑Industrial/Commercial ' ❑Residential Water Supply(shared) 18.GRQ[JT. �_ ,
MATERIAL s EMPLACEMEN
FROM TO T METHOD 8 AMOUNT
❑Irrigation 0 ft. 20 ft Concrete Gravity-Flow
Non-Water Supply Well:
ft ft
❑Monitoring ❑Recovery
Injection Well: ft. ft.
DAquifer Recharge 0 Groundwater Remediation 19..SAND/( AVEL PACK fir e)
eI Storage FROM TO MATERIAL EMPLACEMENT METHOD
❑A quif rage and Recovery . ❑Salinity Barrier ft. ft: -
❑Aquifer Test ❑Stormwater Drainage
f. ft
❑Experimental Technology ❑Subsidence Control i e
2iDRILLINGLOG(attadindili sheets ifn n9)
❑Geothermal(Closed Loop) ❑Trace' FROM TO DESMIPTION(calor,hardness,sollfroclt lyre,grata sine,etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft e•(1 .ft' /6"l .
4.Date Well(s)Completed: a 7 a 3 Well m# Sa ft 6 ft CStI ,�/'„tee.
/ ( t 7-Z ft- tr Dl C`c
oa.Well Location: lfl
72... t ft f �D 6_,eyyfilld
Oft 9 Qdi ft. ft
Facility'IO ner Name ,, • Facility III#(if applicable) , ,—.
w{�<<��QD!_1C ,,, r b1- q." "...5 F'
ft ft. ,p.,]...
%' ein ell it e�87/S - ft ft - ..
Physical Address,City,and Zip n
2LREMARKS • NAAR CI v LlL
11eDinb`= _ SSIk5C3a�rG/�x?
Co ty • Parcel Identification No.(PIN) '_ '!: ,:
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certifica•' n•
(dwell field,one latllong is sufficient)
•
NS°A? 'f6/gS76 N $'A0C/S/"3/. 47/G w �/ j
1/2.3____
Signature o W ee„(r Da
6.Is(sEa)the wells): @Perman ell t or ❑Temporary By signing this J that the weA s constructed in ac by cm* (twas(were)J cordaace
with 1SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 1 copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction&fa n edion and explain the nature of the •
repair under#21 remarks section or on the back of thisfomc 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 wells constructed: - / construction details. You may also attach additional pages if necessary.
For multiple up'ectien or non-water supply wells ONLY with the same cons ruction,you can
submit one form q SUBMITTAL INSTLJCTIONS -
u
9.Total well depth below land surface: • /(2S (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(exarnple-3@200'and 2 l00') construction to the following:
10.Static water level below top of casing: R 0 ( ) Division of Water Quality,Information Processing Unit,
If water!evens above casing,use"+" 1617Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. y. (m.) 24b.For Injection 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 Quality,Underground Injectiog Control Prpgram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield m) Blowing-Rig 24c.For Water Supply&Injection Wells: In addition to sendingthe form to
(SP a Method of test: gg the address(es) above, also submit one,copy of this form within 30 days of
rip Chlorine �.� OZ. completion of well construction to the county health department of the county 136 Disinfection a Amount where constructed.
Form Cdv-I North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013