GW1-2023-02170_Well Construction - GW1_20230306

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information:
14.WATERZONES
Bobby W. Potts FROM TO , DESCRIPTION
Well Contractor Name • ft .+t 20 ft
NCWC 2028-A . . . ft. Aso ft
.
NC Well Contractor Certification Number 15.OUTER CASING(for mnittrpsed wells)OR LINER(if ap Me)
. FROM TO DIAMETER THICKNESS MATERIAL
Ferguson's Well and Pump, LLC 0 ft 7 it G bitv in. 2/61125 dPecc p 2 /
Company Name 16.INNER CASING OR TUBING.( mal dosed oiup)
/` FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: .� M� - 6 3 d ft ft in.
List all applicable well construction permits(i.e.County,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 E V�.[uniaipal/Public ft ft in.
OGeothermal(Heating/Cooling Supply) esrdential Water Supply(single) ft ft m ,
❑Industrial/Commercial ❑Residential Water Supply(shared) .FRitomtOCT - .
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft. 20 n- Concrete Gravity-Flow
Non-Water Supply Well: ft. ft
❑Monitoring ❑Recovery
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 19..SAND/GRAVEL PACK(dmakable) .
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft ft: -
❑Aquifer Test ❑Stormwater Drainage •
ft ft
❑Experimental Technology OSubsidence Control t •
20.DRILLING LOG(attech additional sheets ifnecrssary)
❑Geuthennal(Closed Loup) ❑Tracer FROM TO DESCRIPTION(color,hardness,soithock type,grata site,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) Q ft . .ft C ke t
ft. ft ` �/
C vw
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4.Date Well(s)Completed: tAki Well ID# Ss ft
�7° ft 4�
5a.Well Location: �/n�{,�,, � Cyr
—� /y�/I �� ft 3�S ft l 9.. 'a i ' `
JH � f /�/I�GO/Z� ft ft •
• Facilityl erName FacilitylD#(if applicable)
/// ft ft iy. ..
`7 45- 11/11 !Arta /)/{vL eiii ag 7/G . ft ft •
Physical Address,City,and Zip •
l� '�
21.REMARKS. MAR 2023
County Parcel Identification No. PIN
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one 1at/long is sufficient) 22.Certification: y� /�
3s '331 Q •t'376g`N �'a°y7'3kD//2 rr w .. f, G�[/ l/ /A3/
' Signature of C Tied Well Contractor to
6.Is(are)the well(s): 2ermanent or ❑Temporary By Signing this form,I hereby certify that the well(stwas(were)constructed in accordance
�_/ with 1SA 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 RI copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction irWornration and explain the nature of the •
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 byection or non-water supply wells ONLY with the same construction,you can
submit one fomr. SUBMITTAL INSTUCTIONS
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9.Total well depth below land surface: 340- (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For rntltiple wells list all depths if djferent(exce nple- @200'and 2@100') construction to the following:
10.Static water level below top of casing: A a (ft) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:--1-' _ 6 (in.) 24b.For Infection 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
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12.Well construction method: ry construction to the following: .
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Prggram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 3V Method of test: Blowing-Rig 24e_For Water Supply&Injection Wells: In addition to sending the form to
n the address(es) above, also submit one copy of this form within 30 days of ,
136.Disinfection type: Chlorine Amount: �f% oZ. completion of well construction to the county health department of the county ,
where constructed.
Form OW-I North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013 .