GW1-2023-02072_Well Construction - GW1_20230307

w L.LL 1-Una'nut;nunt(L+'C.MUJ For Internal Use ONLY:
This form can be used for single or multiple wells
I..Well Contractor Information:
BobbyW. Potts 14..WATER•ZONFS :
FROM TO , DESCRIPTION '
Well Contactor Name ft _//t ft
NCWC 2028-A =ft !(/ ft.
NC Well Contractor Certification Number IS.OUTER CASING(for raul6 tad.wdls)ORLINER(ifaptZwb4e)
FROM TO DIAMETER ` THICKNESS MATERIAL
Ferguson's Well and Pump, LLC a t` r/ l t �p,A 5" ?ion l - A/c c j) Z/
Company Name 16.INNER G OR•TUBING.(i�eotlrtmai d )
FROM TO DIAMgJ'ER THICKNESS MATERIAL
2.Well Construction Permit#: 2 C act -:0 0 3 c0' ft. ft ;n
List all applicable well construction permits(i.e.Cotmty,State,'variance,etc).
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ft ft in.
❑M�niblic
❑Geothermal(Heating/Cooling Supply) esiQif dential Water Supply(single) ft ft m.
❑Industrial/Commercial ❑Residential Water Supply(shared) .18..GROUT. —
FROM TO MATERIAL EMPLACEMENT T METHOD&AMOUNT
❑hngation •Well: 0 , ft' 20 ft. Concrete Gravity-Flow
Non-Water Supplye
ft ft
❑Monitoring ❑Recovery
Injection Well: ft ft
,❑Aquifer Recharge ❑GroundwaterRemeIiation 1A.SAND/GRAVEL'PACK$fi able) .. .
❑Aquifer Storage and Recovery ❑Salitti Barll FROM TO MATERIAL EMPLACEMENT METHOD •
ty er ft. ft
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control i t
2tL DRILLING LOGisiltedi addition" shoots Mummery)
❑Geothermal(Closed Loop) ❑Trace:r FROM TO DESCRIPTION(color,hardness,sollirock type,grain Are,etc]
❑Geothermal(Heating/Cooling.Return) ❑Other(explain under 421 Remarks) d ft 70 •ft /r ay
4.Date Well(s)Completed:/z.0.3 Well IDl# 70 ft 575" ft S�� �
' 'S' ft. /f'D /+ E�(W/deyC
"
as Well Location: 9D (jO�' ft.
t f�/
(1'\t A-ChL 11 ( r sae 4-o n f MP((4 co ec ft ft •
Facility/Owner Name Facility lD#(if applicable) ;C,=� s+ r
ft ft 4,,.a l y,,, try .�
D.L 0 van[' n e) Y'Y' /) r in ,) a$75 a _ ft ft 'MAR 0 ?n?3•' .._
Physical Address,City,an Zip21. s
•
J k.CbA1t.1P11 I '7136o(cG.G3I infix;;::f:?.riProcc :FylL!r`i
County Parcel Identification No.(PIN) Li:.;iv;
Sb.Latitude and Longitude in degreeshninntes/seconds or decimal degrees: 22 Certification:
(if well field,one lat/long is sufficient)
4/
27V81—
3s'y3l/2 376 N csl Sr K3(9t�aYl w
Signature of ed c1�iT 1 Contractor
6.Is(are)the well(s):.12Permanwt or ❑Temporary By signing this fora;I hereby certifyr that the wei(srvas(were)constructed in accordance
with 15A 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 Leo copy ofthts record has beenproviukd to the well owner.
If this is a repair,fill cut brown well construction information and explain the nature of fire
repair under#21 remarks section or on the back of thisfonn 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 iryection or non-water supply wells ONLY with the same catsbudian,you cos
submit one forn SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 605 (g,) 24a. For All Wells: Submit this form within 30 days of completion of well
Formuhiple wells list all depths if#ffetent(example-3(g2 0'and2@100) construction to the following:
10.Static water level below top of casing: 7o (ft) Division of Water Quality,Information Processing Unit,
If water keel is abase casing,use"+" 1617 Marl Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. :ir•._ _. 4 (in.) 24b.For Injection Wells: In addition to sending the font 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: Rotary construction to the following: •
(i.e.auger,rotary,cable,direct push,etc.)
of Water
FOR WATER SUPPLY WELLS ONLY: , Division 1636'Mail Quality,Underground
Cent�Raleigh,NC 27699-1636
13a.Yield(gpm) 3 Method of test: Blowing-Rig 24e.For Water Supply&Injection Welly: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b Disinfection type: Chlorine Amouet /,.r oz. completion of well construction to the county health department of the county
�t/ where constructed
Form C W-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality lity Revised Jan.2013