GW1-2023-02049_Well Construction - GW1_20230303

nr,LL KLUIliKII For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts
FROM TO DESCRD'1TON
Well Contractor Name ft 0 it
NCWC 2028-A - :fL ft
NC Well Contractor Certification Number 15 OUTERCASING of�lfi cxied�rells ORLAVER d
FROM TO DIAMETER TSIC1� MATERIAL
Ferguson's Well and Pump, LLC 6 rLqr2 fc ;n a, dopcSD12211
Company Name 16.INNER CASING OR T 181ING; o d
R FROM TO DIAMETER Turk-w-S MATERIAL
L Well Construction Permit#: t�w[J �66 5 ft ft in
List all applicable-11 cautruction permits(Le.Cow*,State,Ymimice,etc.).
ft ft iR
3.Well Use(check well use): 17.SCRft.
Water Supply Well: FROM TO DIAMECER SLOT SIZE THICKNESS MATERL41
ClAgricultural ft & in
❑Muni blic
❑Geothermal(Heating/Cooling Supply) esi@3� dential Water Supply(single) ft ft hL
❑Industrial/Commercial ❑Residential Water Supply(shared) 1&GROUT
'Non-Water Well: OM TO MATERIAL Eh PLACEMENST METHOD&AMOUNT
❑� 0 FR ft 20 ft Concrete Gravity-Flow
ate
❑Monitoring ❑Recovery ft ft
Injection Well: & ft
❑Aquifer Recharge ❑GroundwaterRemediation 19.. VSI:PACK
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EbelACEMENTrlMOD
ft. fE
❑Aquifer Test ❑Stormwater Drainage
[Experimental Technology ❑Subsidence Control ft. ft. t
2X&&DRILLINGL00 si `adilEei�alaheel,
❑ cuthesnral(Closed Loup) ❑Traces FROM TO DLSCTi1P1TUN edar hardnem softoc t rive,Vida size,de
[]Geothermal a4catingCooling Return ❑Other(explain under 421 Remarks)- ft ft
�
4.Date WeII(s)Completed: 3��Well ID# Zz2
ft ft
�
Sa.Well Location:
LdX ft ft
Facility/OamerName Facility ID#(if applicable) ft &
Let%ce er d8 7118 & ft
Physic'n Address ,and Zip
om 6 %q q5 540 -7 MAR 0 2023
County Pamcl Identification No.(PIN)
5b.Latitude and Longitude in degrees/minuteslseeonds or decimal degrees: 22 Certification•
(ifwell field,one lablong is sufficient)
J 7!D W,81702 rr N. 2°YA '5,�r W 26. 5? Z149
_ _ igffiture o fied Well Con for Dat
6.Ty(are)the well(s): BPermaneat or ❑Tetnpotary By sigrcrrg lids fong I hereby certify that the weA(s)lvas(were)constructed in accordance
with 15ANC4C 02C.0100 or 15ANCAC 02C.0200 Wdl ConstructionStandords and that a
7.Is this a repair to an existing well: ❑Yes or ego copy of this record has been provi&d to the well owner.
If this is a repair,fill out known well eorutnwfron brformaHon and explain the nmwe ofthe
repair rattler#21 ranks section or on the back of thisfomn 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well _
&Number of wells constructed: construction details. You may also attach additional pages if necessary.
For muhlple irgecumornon-water supply wells ONLY with the sameaaasbudion you can
subs&aneform SUBAIMAL INSTUCTIONS
9.Total well depth below land surface: ,�0 (B) 24a. For All Wells: Submit this form within 30 days of completion of well
For nn&ple wens list aU depda if& erew(example-3(a)200'�a)nd 2@100� construction to the folloming:
10.Static water level below top of casing: YU (ft) Division of Water Quality,Information Processing Unit,
Ifwater level is above casing;use"+" 1617 Marl Service Ceater,'-12aleigh,NC 27699 I617
11.Borehole diameter. (in-) 24b.For Infection We%: In addition to sending the forest t61he address in 24a
Rota above, also submit a copy of this form within 30 days of completion of well
12 Well construction method: ry r:onstraetiun to the fulloming:
(i.e.auger,rotary,cable,direct push,etc.) "
Division of Water Quality,Underground hrjectio&Control PVgram,
FOR WATER SUPPLY WELLS ONLY: 16M Mail Service Center,Raleigh,NC 27699-16M
13a.Yidd m / Blowing-Rig24c.For Water Suonly&Iniection Wells: In addition to sendingthe form to
(SP ) Method of teat:
the address(es) above, also submit oae copy of this form within 30 days of
-0b.Disinfection type: Chlorine Amount.• OZ• completion of well construction to the county health department of the county
where constructed_
Form CW 1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013