GW1--04293_Well Construction - GW1_20230626

W ELL lAJININ •KUl;11UN KECUI(U For Intemai Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor 7nfoima0ion: •
Bobby W. Potts • 14:.w ITIODNES : -..... ::.;
FROM TO • , T SCRII7TON
Well Contractor Name - ft y 1 n ft
NCWC 2028-A ft SSQ ft ' •
NC Well Contractor Certification Number • • . 15:O11TERCASQEG(fvt isolismed.wells GRL NER(ifsDpfinble)
. FROM TO DIAMETER' THICSNESS MATERIAL
Ferguson's Well and Pump, LLC . I. ('f4 a ft G s z', S ®re spWA 1
Company Name 16.INNER CASING ORTURINGOjecttsermaldosed-loop)
1. /� FROM TO DIAMKJTR THICKNESS MATERIAL
2.Well V Construction Permit#: • . •'-a o a 3' 6 SQc ft ft. • in.
List all applicable well construction permits(Le.County,State,Variance,etc). ,
ft ft M.
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE , THICKNESS MATERIAL
ft ft is
❑Agncultural ❑ ipal/Public
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft is -
[
❑IndustriaUCommercial ❑Residential Water Supply(shared) ,18:.GRQ17T.. _
FROM TO MATERIAL ' EMPLACEMENTMETHOD&AMOUNT
❑Imgation • 0 ft 20 ft Concrete Gravity-Flow
Flow
Non-Water Supply Well: • - -
ft. ft
❑Monitoring ❑Recovery •
Injection Well: ft. ft
❑Aquifer Recharge ❑GroundwaterRemediation 19&UW/Q2AEL PACK(lfimelfesble) .. •
❑Aquifer Storage and Recovery . ❑Raiinity Barrier FROM ,TO MATERIAL EMPLACEMENT METHOD.
ft. ft
DAquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control e
20:DRILLING LOG.(atlach addiihi tal sheets ifneeesaars)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCUPTIoN Kolar,hardness,soll/roclttype,frith she,etc)
OGeothetmal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 6 ft Ss -ft
4.Date Well(s)Completed:(//A 3 Well IB# S"S f t �� R �Q/ty to
sa ell Location: r 7 S ft n ft �„�
• �r-ova.r" irnit)(L t( `�d ft ley
ft 6 t0t" 'I'
Facility/Owner Name ^ •e FacilitylD#(if applicable) ft ft ;� .,e d t, t......r •ek,f
a
t S I Sl f lier (Zit") 1/U1.y H t/.strlvill, - ft ft i
Physical Address,City,and Zip J a�17a a 21.REMARKS I I,iv :• n?
• ke.ry4e rs 0 to -O tt l a l a r c.,.. P r:-.7-yn,',e,g Una
County Parcel Identification No.(PIN) L':°et Y=;:.fxa
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
3 5°‘?S S-t .f g��pi g"� °1'9 D 3,OCA Y w
S' of eel ntractor 444/213-
6.Is(are)the well(s): ermaneat or ❑Temporary By signing this form 1 fib,cer that the well(s)lvas(were)constructed in accordance
with 15A NCAC 02C.0100 or 15ANCAC 02C.0200Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 1glrlo copy of thus record has been proviabd to the well owner.
If this is a repair,fill out/vwwn well conthuction information and explain the nature of the
repair under#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
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple'Venda,or non-water supply wells ONLY with the same construction,you can
.submit one form SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: • 4S (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths((ftb erort(example- 000''�and 2(t100') construction to the following:
10.Static water level below top of casing: d!l (ft) Division of Water Quality,Information Processing Unit,
If water level`ts above'casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter--1- _ Rotary •
4 (m.) 24b.jfi'or 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: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground InjectiolkControl Program, •
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield m) /v/� Method of test: 9g Blowin -RI 24e.For Water SUM*&Injection Wells: In addition to sendingthe form to
(Sp
the address(es) above, also submit one copy of this form within 30 days of
•13b.Disinfection type: Chlorine Amount /D oz. completion of well construction to the county health department of the county ,
�G where constructed _ i
Form C W-1 - North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.20i ,