GW1--04289_Well Construction - GW1_20230626

W Lt LL 1,:l1115.1KU1;11UN KLLUKU For Internal Ilse ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts ' •
FROM4T$R TO , DFSCRIP'ITON
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Well Contractor Name ft A.0 ft
NCWC 2028-A . 3 ft
NC Well Contractor Certification Number IS.t)UTER Gliot�tli�easad.w koR NERfd )
Ferguson's Well and Pump, LLC . PROM TO • arArdErER THIt�vFss MATERIAL
,� '7 S ftTU a a i6//zs PUCS�2z/
Company Name 1 CASING OR G'.(e aaidosed-loop)
PROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ` US ' Z 6.2 3 = U !g a. ft ft in.
List all applicable well construction permits(i.e.Colony,Stale,Variance,etc.). .
f. ft m.
3.Well Use(check well use): 17.SCREEN
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Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
. ft ft in.
❑Agricultural ❑ mpal/Public
❑Geothermal(Heating/Cooling Supply) :,.MA Water Supply(single) ft ft in
DIndustrial/Commercial DResidential Water Supply(shared) ,la.GROL,T _
FROM TO MATERIAL . EMPLACEt111dENTMETHOD&AMOUNT
• DIrigation
Non-Water Supply Well: 0 , ft 2() ft Concrete Gravity-Flow
fc ft
❑Monitoring ❑Recovery
Injection Well: ft. ft
❑Aquifer Recharge ❑GroundwaterRemediation 19..Si1AtD/Gl1e}VELPACKif.arrplirahle) .
DA et$tora and PROM TO MATERIAL EMPLACEMENTMETHOD
4uif Storage very °Salinity Barrier ft ft: •
-
DAquifer Test DStotmwater Drainage ft
[Experimental Technology ❑Subsidence Control v
20C DRILLING LO (attedi i3lliodsheetsifureessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRU'TION(cdor,hardness,son/rock type,grain 07e,etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) (/, ft. 75 .ft /1(oy jy/
l 4.Date Wells)Completed: tt3 Well IDli 7-S q� s'(►'`�!S "f�(�'
90 ft
`l S ft e /sorA
52.Well Location: co-
-�lS 2-51p $ Zsf. vs
(cCdiN, 7Q
• L
Facility/OwmerNaxos Facility Wit(if applicable)
-730'Ge.Ch face �dCes �lt/C tVn iccr►tJl(� ft ft. •
^- € a_)
Physical Address,City,and Zip Z
IL REMARKS ���� H ;9 J_�►L3
`1-lenk'e.rSor. G1[.rjlb1 S?ciy
County Parcel Identification No.(P ) 11ttvi"71;lt<:IN ,^ ."' _'_ g t o n21
t
asstia'�'
R.Latitude and Longitude in degreeshntimntes/seconds or decimal degrees:
(dwell field,one lat/long is sufficient) 22.Certification:�f
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35°Ai%Cl/gee ref N 8A1) 7i` wog /' w %i '' � sV,Ii.e6-
I'�_ Signatureea'3 ye°ned Wellctor 04/al-
6.Ia(are)die'well(s): 12 a Anent or OTemporasy By signing this form,I hereby certify that the well(epwas(were)constructed in accordance
with 15A NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing weir: °Yes or o copy of this record has been provitkd to the well owner.
If this is a repair,fill out brown well construction&ormation and explain the nature'of the
repair tinder#21 remarks section or on the back of this form. 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: / construction details. You may also attach additional pages if necessary.
For multiple trgection or non-water supply wells ONLY with the sante construction,you can
submit one form. ''!! SUBMITTAL INSTUCTIONS
9.Total well depth below land surfaces +7t%7 (g,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi ere nt(example-3(4200'and 2(100') construction to the following:
10.Static water level below topof casing: Division of Water
g S� (ft) Quality,Information Processing Unit,
If water level is above'casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: .-i 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
12.Well construction method: ry construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injectio*Control Prpgram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gym) S Method of test: Blowing-Rig 24a For Water Suindv&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: OZ. completion of well construction to the county health department of the county ,
J V where constructed. _ ,
Form GW 1 - North Carolina Department of Environment find Natural Resources-Division of Water Quality Revised Jan.2Oi •