GW1-2023-02047_Well Construction - GW1_20230303

W ELAL 1LU1NN-1XlJ 11U1V RI C()RD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts FROM R TO ]DESCRIPTION
Well Contractor Name ft ft
NCWC 2028-A - ft rt j
NC Well Contractor Certification Number 18:OUTLR.CAS1NG ormnl6smadwdis ORLBOR if ble
Ferguson's Well and Pump, LLC FROM TO DIAMETER
,U a1a
$ cc/
Company Name 16.INNER G OR TU&DTG:lon6dugmal dread-1
.R' FROM TO D TSICKNFAS I MATERIAL
2.Well Construction Permit#: ' C)Z. _ _ d ba 3 S ft ft ;n
List all applicable well construction pemrits(1.e.Cowrly,State,Yari=e,ek.).
ft ft in
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER SLOTME-1 THICKNESS I MATERIAL
ft ft •in
❑Agricultural a❑ p blic I --+
❑Geothermal(Heati4Cooling Supply) 15 esidential Water Supply(single) h ft m
❑IndustriaUCommercial ❑Residential Water Supply(shared) 18-GROCT.. *_
FROM TO MATERIAL EMPLACEAUMMETHOD&AMOUNT
❑Ini tits 0 ft 20 't Concrete Gravity-Flow
Non-water supply well:
❑Monitoring ❑Recovery ft ft
Injection Well: ft ft
[]Aquifer Recharge ❑GroundwaterRemediation 19.-IU /QIAYSI:'PACK e
❑Aquifer Storage and Recovery ❑Salinity Barrier PROM TO MATERIAL F.MPLACELIIFNTMET1101)
& fr ,
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control p
30:11RI1LLIN=LOG atta&'addltiiiaalydeeb
❑Geothermal(Closed Loop) ❑Trau:r FROM TO DESt1t1P1TUN cobr harduess6 aiftark ryW,gain dze,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) ft .ft
ft � it
4.Date WeR(s)Completed: Well ID#
to r
52.Well Location: e O
t &4 ft
ft ft
Facilit00waer Name Facility MN(if applicable)
ft ft.
f h� wpitwf� `31ri<!In a8 7d
ft [t _
Physical Ad
dress,City.and Zip Ni A c
2L REMARKS. � c-
(l/1 MMhP t 16(A f 3 a a(MCb
County Parcel Identification No.(PIN)
Sb,Latitude and Longitude in degmeshoioutes/seconds or decimal degrees:
(ifwell field,are lafAong is sufficient) 22.Certi5catio
S, 9 t/lr0 kFN S(et �SAyt�w
Signmm of well ntrastor 5D ('p
6.Is(are)diewell(s): ermanent or ❑Temporary
BY sighing this forcer 1 hereby cerkfy drat the weA(s)`was(were)constnrcted in accordmice
with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Comtruadon;Standards and that a
7.Is this a repair to an existing wt71: ❑Yes or o copy of this retard has been pmvf&d to the well owner.
Ifthis is a repair,fill out/mown well consbwdon a formation and explain die nature ofthe
repair miler 921 rmwb section or on ere back of dwfomi. 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.
Fermultiple iryecum ornon-water supply wells ONLY with the same cmutrud wi;you can
submit areform SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: _(ft) 24. For An Wells: Submit this form within 30 days of completion of well
For n.&pk well;list all depths tf&ff--t(exmnple-3@200'and 2@100� construction to the following:
10.Static water level below top of casing: A) Division of Water Quality,Information Processing Unit,
if water level is above casing,use"+" / ' 1617 Matz Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. : lD _(in) 24b.For Iniection WeBs: 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 WeL construction method: Rotary construction to the following--
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injectiog Control Pipgram,
FOR WATER SUPPLY WELLS ONLY: 1636 Matt Service Center,Raleigh,NC 27699-1636
Blowing-Rig24e.For Water Supply&Iniection Wells: Tn addition to sendingthe form to
13a.Yield(gpm) Method of test the address(es) above,also submit one copy of this form within 30 days of
13b.Disinfection type: Chlorine Amount. `/7 OZ, completion of well construction to the county health department of the county
r�Gr where constructed.
Form E W-1 - North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013