GW1-2023-02036_Well Construction - GW1_20230303

WE'LL CUNVa•1•KUC LION RECORD For Internal Use ONLY:
' This form can be used for single or multiple wells
1.Well Contractor Information: • .
Bobby W. Potts •14:.WATERZONES:: ,
Y . FROM TO , DESCRIPTION
Well Contractor Name ft 07/0 ft I
NCWC 2028-A • , ft 3 ft • ' -
NC Well Conteactot Certification Number • ' . 15:OUTERtASING(forn eased'aella)ORLINER(if )
. PROM TO DIAMETER' TffiCENESS MATERIAL
Ferguson's Well and Pump, LLC © ft (Os kol5 in- 24/125- i',icSpX2i
•
Company Name 16.INNER CASING ORTUBING fneidaermsd dosed-loop).
,e. /h, ' r FROM TO DIAME12R THICKNESS MATERIAL
2.Well Construction Permit#: �6? 1 -• v.6 t••�l • ft ' ' ft in.
List all applicable well construction pentrits(ie.County,State,Variance,etc.). •
n - ft in.
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑ he ft ft is
OGeothermal(Heating/Cooling Supply) esidential Water Supply(single) !t ft in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) la GRCIUT.. • - .
FROM TO MATERIAL EMPLACEMENT METHOD 8 AMOUNT
❑Irrigation 0 ft 20 ft Concrete Gravity-Flow
Non-Water Supply Well: is ft
❑Monitoring ❑Recovery
Injection Well: ft ft '
❑Aquifer Recharge DGroundwater Remediation 19.SAND/GllAVEL'PACli1 f anpffublc) '
❑Aquifer Storage and Recovery . ❑Salinity Barrier PROM TO MATERIAL ft ft • EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage •
ft ft
❑Experimental Technology OSubsidence Control p
20:DRILLING LOG(attadi'adrsremT ffa�rssar9)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESLIIIPTTON(calor,hardness,soturoel:type,pram she,etc)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 2 o .ft' C/Qy
::: mP1et /
Well ID#• ft (00Location: i '� YX.5 . : (.�GS Kin %'e-
T) U Sn oic ft
,
Facility/Owner Name ;CE-acfe
Facility ITN(iff applicable) ft ft
•�.) V S nd ,- . ft ft - ---J\,'-`':. :tip'IA:-_'-d
Physical Address,City,and Zip ZL REMARKS Th
jtln err»ae 7V 19Wit'704, MAR 0 i.Ot3
nary Parcel Identification No.(PIN) ' , 2_`� r; ( :i:S -
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: - .,"'` - ;
22.Certifies•o t°
(if well field,one lat/long is sufficient) •
35o39 rq / 75 r N �ila:°Y1'l a/7/g �r W I
Signature of Cer ided well n Date
6.Is(are)the well(s): Et ermaneat or OTemporary
By signing this form,I hereby eerbfy that the well(spwas(were)constructed in accordance
�� with 1SA NCAC 02C.0100 or 15ANCAC 02C.0200 Well ConsduetienStardards and that a
7.Is this a repair to an existing will: ❑Yes- or 2N copy of this record has been provided to the well owner..
If this is a repair,fell out known well construction information and esplavn the nature of the
repair meter#21,remarks section or on the bad*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 wells constructed: /r construction details. You may also attach additional pages if necessary.
For multiple infection ornon-water supply wells ONLY with the same construction,you can
submit one form SUBMITTAL INSTUCTIONS
•
9.Total well depth below land surface: t2 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For ncdtipk wells list all depths 0' erent(example- 00'and 2@100') construction to the following:
10.Static water level below top of casing: 9'0 (ft) - Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: ,— _ 6 _(in_) 24b•For Inieetion 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 Injectiop:Control Pipgram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
Blowing-Rig 24e.For Water Sunuly&Injection Wells: In addition to sendingthe.form to
13a.Yield(gpm) $ Method of test: g g the address(es) above, also submit,one copy of this form within 30 days of
136 Disinfection type: Chlorine Amount: �'Q oZ. completion of well construction to;the county health department of the county r
where constructed -
Form OW-I -- North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013