GW1-2023-02038_Well Construction - GW1_20230303

n n■,■,a—villa I ItU 1.1Hirt Kr,cui(U For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
BobbyW Potts 14:.WATERZONE3:: ".. ...
. FROM TO - , DESCRIPTION
Well Contractor Name W � ft
NCWC 2028-A - ��p[t ft.
•NC Well Contractor Certification Number 15.OUTER CASING(foem miff-eased.walls)ORLINER(if ble)
IAMETER17E:NESS MATERIAL
Ferguson's Well and Pump, LLC PROM 0 "
TO ft Dm. .
Company Name 16.INNER CA81NG OR TUBTNG,(neatbermal dosed-loop).
G FROM TO DIAMETER THICKNESS MATERIAL
2 Well Construction Permit#: •• . .26 Z Z —f660 $ 0 ft. ft. ' in.
List all applicable well construction permits(Le.County,State,Variance,etc.). •
-
f. ft . at.
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural OM!r). 'pal/Public ft ft in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft. m ,
❑Industrial/Commercial ❑Residential Water Supply(shared) • 18.GROUT M • _
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft 20 ft Concrete Gravity-Flow
Non Water Supply Well: ft. ft
F
❑Monitoring ❑Recovery
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Reanrdiation 19..SAND/GRAVEL PACK.(if b1e) •
er Storage and Recovery FROM TO MATERIAL EMPLACEMENT METHOD
❑A quif g very . ❑Salinity Barrier ft. ft..
❑Aquifer Test OStormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control e
20:DRILLING LOG(attsd affirms!sheets ifaetacaaey)
❑Geothermal(Closed Loop) ❑Tracer FROM To DESiRMION( hardness,sell/rock type,gram rile,etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 5 el .ft. C ,I a'
•
4.Date Well Soft ft s)Completed:p 3 Well ID# )/ Ct -C
6 Sit v ft A,_ • C/
52..,Well Location: ft v 1v ft
V it avyi st tip p ft. ft
Facility/Otwer Name Facility ION(if applicable) �' '
(7, iV r eei te_"le S1Lr c90'7t g ft ft R } �}
Physical Address,City,and Zip 2L REMARKS M�,R 'J 20P L�
,tne6mbr • 'i,o 9 -913 -14896 - ..77-, pE.: :: -. .:3 t nli
County Parcel Identification No.(PIN) ., D`,;';0;";' 'i
Sb.Latitude and Longitude in degreeshminutes/seconds or decimal de
grees: 22.Certification:
(if well field,one laUloag is sufficient)
jeti,,W/A--
Signature `-15 6 `S�3sez�-c, F2 Vii1iisr' W , o . cd W 0443
6.Is(are)the well(,): ermanent or OTetnporaryBy rr8 this form,I hereby by eertifp that the weR(sp.was(were)constructed in accordance •
with 15ANCAC 02C.0100 or ISANCAC 02C.0200Well Construction Standards and that a
7.Is this a repair to an existing well: OYes or B‘ copy of this record has been provided to the well owner.
If this is a repair,fill out hmwn well construction itrformation and explain the nature ofthe •
repair wider#21 remarks section or on the back of this fomi. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details of well
8.Number of wells constructed: ( construction details. You may also attach additional pages if necessary.
For multiple it#ectian or non-water supply wellsONLY with the sane construction,you can
submit one form SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 3/\3- (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdrfferent(example-3(a 200'and 2 ,100') construction to the following:
10.Static water level below top of casing: AO (ft) Division of Water Quality,Information Prorating Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
IL Borehole diameter: :i._ _ 6 (in.) 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 Injectiogs Control Pipgram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 09\0 Method of test:. Blowing-Rig 24e.For Water Sam*&Iniection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
Chlorine completion of well construction to the county health department of the county
.13b.Disinfection type: Amount: 0 OZ.
where constructed
Form C-MI-I North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013