GW1--04290_Well Construction - GW1_20230626

,,••L•U•a a.vt11►7r.Aux..11VP1 11La LVHu • For Internal Use ONLY:
This form can be used for single or multiple wells
4
1.Well Contractor Information:
Bobby W. Potts - 14:.WATER-2ZIES,_ -...... .
FROM TO . , DESCRIPTION
Well Contractor Name ft.
/60 ft.
NCWC 2028-A -it :A 41 ft . - 1 • =
NC Well Contractor Certification Number 1S. CAS G for dwells)ORL1NER(ifa fable)
. FROM TO DIAMETERS THICKNESS MATERIAL
Ferguson's Well and Pump, LLC ' y ft p �5 li 9 !/Cs �Zi
Company Name lb INNER Cki�SIlr1G OR TIIffiNG( uthermal -loirp)
,e • FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: •Q a( a 610 (S'1.5. ft • ft . m.
List all applicable well construction permits(i.e.County,Stale,Variance,etc.). .
f. ft. in.
3.Well Use(check well use): 17 SCREEN
Water Supply Well: . • FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft • ft m.
Agricultural ❑ Public
❑Geothermal(Heating/Cooling Supply) estater Supply(single) ft ft in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) :18:.( MT.. ,
FROM TO MATERIAL EMPLACEMENT METHOD 8 AMOUNT
❑Irrigation
Non-Water Supply Well: 0 ft 20 ft Concrete Gravity-Flow
•
ft ft
❑Monitoring ❑Recovery
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 1A.SAND/GiAVEL PACKf f> ieabie)
!7 Storage and RecoveryPROM TO MATERIAL EU PL t MINT METHOD
❑A gulf g ❑Salinity Barrier ft ft: -
❑Aquifer Test ❑Stormwater Drainage - .
R ft
❑Experimental Technology ❑Subsidence Control i
20.DRILIINGLOG(attad ad inl sheets ,Mammary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCITIONScdoror,hardness,sell/rock type,asin axe,etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) O ft o .ft C 4C1 .
• c` ^^ ft / ft �j�
4.Date Well(s)Completed-, /9 Well ID# �D ft /(� ft S4 as 1 D /4,e
Si Well Location: !!!!! ��ft. �� ft �" ��e/C
�0,�,Gt)l�, f�' �iatalt la`v.ft. An ft.
. ' �ira(A)/74C-
Facility/Owner Name/�� - Facility ID#(if applicable)p A ft ft
•
I( 4 Itil�+tlk I'h, -(?! VGhrle/SnhUJ(t p R1 1 a ft. ft I,r" 1 •' "-. t• : a
Physical Address,City and Zip •
21 REMARKS
"Perief�rtn►-, • - R5 591o43 .s i JUN 5ZUZ3
County ' - Parcel Identification No.(PIN)
ngrdegrees/minutes/seconds or decimal lniwt d. -2 a r.^^s t..4�)n`1
A.Latitude and Longitude in degrees: 22.Certification: D tied Oks,
(if well field,one lat/long is sufficient) •
3Soir,v,t/7 $•fi,,N $,e02,9 `56190a8 w
S' o • ea W Contractor 440-2—
'
6.Is(are)the well(s): ernranent or ❑Temporary By si2n8 this form I here (�
by certify that the well s as(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well ConstructicuStandards and that a
7.Is this a repair to an existing well: ❑Yes or o copy of this record has been ptvvi&d to the well owner.
If this is a repair,fill out blown well construction intimation and explain the nature of the
repair under#21 remarks section or on the back of thisfonn. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: ( construction details. You may also attach additional pages if necessary.
Fornmltiple ityectron or non-water supply wells ONLY with the same cwnsbucdion,you can
submit one form SUBmri-rAL INSTUCTIONS
9.Total well depth below land surface: .A$' c (g,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdlerent(example-3@200'and 2 .100') construction to the following: '
10.Static water level below top of casing: /1) (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. :i._ _ (m.) 24b.For Inflection Wilts: 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 InjectiogrControl Pepgram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gput) 3 0 Method of test: Blowing-Rig 24c.For Water Sum*&Inflection Wells: In addition to sending the.form to
, the address(es) above, also submit one copy of this form within 30 days of
Chlorine _��' oz. completion of well construction to the county health department of the county
13b Disinfection type: Amount where constructed.
Form OW-1 - North Carolina i
Department of Environment and Natural Resources—Division of Water l2uality Revised Jan.2013