GW1--04281_Well Construction - GW1_20230626

n.10...a.l.Vl\O1nu(Amin i,ll4 .Vt(L For Internal Use ONLY:
This form can be used for single or multiple wells I
1.Well Contractor Information:
BobbyW. Potts 14.wATnzo s: ... ...
. FROM TO • , DESCRIPTION
Well Contractor Name ft ft
NCWC 2028-A ft 7/0 ft -
NC Well Contractor Certification Number 15 OUTER CAS NGf[oi od )ORL NERCdapp&sIde)
. FROM TO .' - DIAMETER THICKNESSMATERIAL
Ferguson's Well and Pump, LLC ' D ft, /_,a 5 m 214 r .5 cs p12 21
Company Name 16.INNER G ORTtMvG.(geadsernal dosed )
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: • .G.a a • (06 $ . ft. . ft
List all applicable well construction pennons(i.e.Cow*,Stale,Variance,etc.). •
ft ft in.
•
3.Well Use(check well use): 17.SCREEN
Water Supply Well: • FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
ft ft in.
❑Agricultural ❑ cipal/Public
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft in
Olndustrial/Commercial ❑Residential Water Supply(shared) 18..GRCUI.. • - •
PROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lnigation 0 1t 20 ft" Concrete Gravity-Flow
Non Water Supply Well: ft ft k
❑Monitoring ❑Recovery
Injection Well: • it ft
❑Aquifer Recharge ❑GroundwaterRemediation 19..SrJID/QtAV LPACKifliapliwbre) •
❑A er Storageand Recovery FROM TO MATERIAL EMPLACEMENT METHOD
quif very ❑Salinity Barrier ft fr
❑Aquifer Test ❑Stormwater Drainage ft. Ft
❑Experimental Technology ❑Subsidence Control .. e
20:DRU LOG(itsadi'addi'al ifs r9)
❑Geothermal(Closed Loop) ❑Tracer PROM To DESCRIPTION(color,hardness,so&llroctt L grain she,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) a ft 7 ) .ft ^ a`y` ,
4.Date Well(s)Completed:��/(1111 VA 3 Well ID# 70 ft ``� f t l�1 /K�S'`�We
/.5 ft. gr A ft Aim r/C-
5a.Well Location:
Yowl,
�1 A, ft. ft 6,4Q
, Q o'!/fl`
� r+rAvIc l Aiv,thii.j ! Yown' Cowes eons(TIAA i o s1 ft. ft IN y� •
Facility/Owner Name Facility (if applicable)ID#
5'(DQ YC1.4: gran S Ttvi I. 'Buc 1 n .
ft.ft ft g ft. :±�.%...a L.,..l V D. ;iJ
Physical Address,City,and Zip 21.REMARKS J U I V 2, L° 2023
To tk O(i36t goy8fa
County Parcel Identification No.(PIN) InrC,G a l'.n Pt7 /1.:%`j UJrki
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: DL 4.;.- "1G
•
(dwell field,one lal/long is sufficient) 22.Ce tro
° 4
' v• �Aoiy0, Y RV w sig.... well Con for Ø /u
6.Is(are)the well(s): ermanent or ❑Temporary By signing this lam;I hereby cm*that the well(s)Iwas(were)constructed in accordance
with I5A NCAC 02C.0100 or ISANCAC 02C.0200 Well ConstructionStandarde and that a
7.Is this a repair to an existing wdb ❑Yes or o copy of this record has been provirkd to due well owner.
Uthis is a repair,fill out brown well construction information and explain the nature ofthe •
repair under#21 remarks section or on the back of thisform. 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.
Formulaple infection or non-water supply wells ONLY with the sane construction,you can
subunit one fo m SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 1 (g,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iferent(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: /50 (ft.) Division of Water Quality,Information Processing Unit,
If water!evens abov casing,use"+" 1617 Marl Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. •: 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 Injection Control Prpgram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636 _
13a.Yield(gpnr) /5 Method of test: Blowing-Rig 24c.For Water Sunni!&Injection,Wells: In addition to,sending the form to
the address(es) above, also submit one copy of this form within 30 days of
136 Disinfection type: Chlorine Amount /_ 2. oz. completion of well construction the county health department of the county
(Q where constructed.
i
I .
Form C W-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013