GW1--04282_Well Construction - GW1_20230626

WYL'la,a,a vim aII u L.1 It/11 IK1LaL:VI(U
For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W: Potts MA TO , nrioN
Well Contractor Name - ft 00 ft.
NCWC 2028-A ft. 70� ft
NC Well Contractor Certification Number • '1S:OlJTERCtSINGfizjd )ORLlNER(d'a XnMe)
FROM TO . ' DIAMETTR THICKNESS MATERIAL
Ferguson's Well and Pump, LLC ' . 0 3 S (,t o�S"` ?-/(o i t d C SD�12/
Company Name • . 16.INNER CASING OR TUBINGWeithe rmal dosed-loop)
/ FROM TO DIAMETER THICKNESS MATERIAL
a wen Construction Permit#: • r l^'t - �. � ft. ft in
List all applicable well constrvcton permits(Le.County,Stale,Variance,etc.). .
ft ft in
3.Well Use(check well use): V.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft ft m.
❑Agricultural ❑Munic lit
OGeothermal(Heating/Cooling Supply) esi®R dential Water Supply(tingle) ft ft in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18:. OUT
FROM TO MATERIAL 1 EMPLACEMENT METHOD a AMOUNT
❑Irrigation 0 ft. 20 ft Concrete Gravity-Flow
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation L9.SAND/GliAVEL'PACK;(lt e) ..
❑Aquifer Storage and Recovery _ ❑Salinity Barrier FROM TO MATERIAL ft tft: ` . EMpLACEMEI`PTrE1IIOD
DAquifer Test ❑Stomiwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control
20:DRJ L M LOGlittachailiiiiimil sheetsifuecessary)
❑Geothermal(Closed Loup) ❑Tracer FROM To DL RIPTION(color,hardness,seturoclt type,grain doe,etc)
OGeothermal(Heating/Cooling Return) 2 DOther(explain under#21 Remarks) l© ft `l O It a lay
4.Date Well(s)Completed: Q oZ 3 Well IDS (T 9 f t 7so f t sa' S'e' /r
Sa well Location. S S ft. 3 ft.
. .A6-ra w
1'
Dr+n-5 [vAAr1c ft ft •
Facility/dealer Name /�
it FacilityFa ID#(if applicable). ft. ft.
A p-.al . 7Cctufr1 W .r P17 3 ft ft w t.E,.,s @R.e i V t.-,1
Physical Address,City,and Zip .. .
2L REMARKS
' 'Pow(z Pcx, ,:1-j ' Z3- u'l JUN ZUZ3
County PlreelIdentifcationNo.(PIN) .
inlot-yzr. i:i-n ;�c,.,,,,,".• n Ili,
Sb.Latitude and
Longitude
degrees/minutes/seconds or decimal degrees: 22.Certification:
D+;rn3.i 3' s
(if well field,one lat/long is sufficient)
3S°/////7► OR (ISd''l $xa/7'Da 'f(a "7z // w
Signature of 'fled Wel 'n tar to
r-/------
6.Is(are)the wel(s): 2<rmanent or ❑Temporary
BY signing this form,1 hereby cerlify that the weA(s)rwas(were)constructed in accordance
with NSA NCAC 02C.0100 or 1SANCAC 02C.0200 Well ConstrucctionStandards and that a
7.Is this a repair to an existing well: ❑Yes or 1211( copy of this record has been prrvid alto the well owner.
If this is a repair,fill out brown well construction information and explain the nature of the •
repair under#21 rennwlcs section or on the back of thisfon& 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: / constriction details. You may also attach additional pages if necessary.
Form multiple by'ectun or non-water supply wells ONLY with the sane construction,you can
submit one Alm SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 3 0&5 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Form multiple wells list all depths& eran(example-3(@200'and 2®100) construction to the following:
10.Static water level below top of casing: /0 (ft) Division of Water Quality,Information Processing Unit,
If water level is abov2 casing,use"+" // ' 161r7 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter.-.— _ `Q (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 Injectiot Control Prpgram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 1° Method of test: Blowing-Rig 24c For Water Sunnly&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this farm within 30 days of
13b Disinfection type: Chlorine Amami 4/v •oz. completion of well construction to the county health department of the county ,
where constructed. , 1
Form CAW-I North Carolina Department of Environment and Natural Resources-Division of Water(Quality Revised Jan.2Q1