GW1--04295_Well Construction - GW1_20230626

w Ma.a,l.Ul\a1.KU IL.11U111 1tLL:UILL For Internal Use ONLY:
This form can be used for single or multiple wells
1.Nell Contractor Information:
Bobby W. Potts 14.WATER.BO$IFS,: ;
FROM TO - , DESCRIPTION
•
Well Contractor Name - ft.
/O/ ro ft
NCWC 2028-A ft ft:
NC Well Contractor Certification Number . , • • 15.OIITERCASING(for.moI6s ad.Wells)ORLINER(ifapp e)
FROM TO DIAMETER THICKNESS MATERIAL
Ferguson's Well and Pump, LLC ft ft.� S in. �
aiji/as vcSAg2/
Company Name . 16.INNER G OR- G':(Raeudsermal dosed4onp)
F FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: b5 S '"2 0 2-2 : 0 Z 2.0 . ft -ft in.
List all applicable well construction permits(i.e.County,State,Varrance etc.). . .
ft. ft in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft in.
OGeothermal(Heating/Cooling Supply) esidential Water Supply(single) ft it in
❑IndustriaUCommercial OResidential Water Supply(shared) 18 GROVI
FROM TO MATERIAL * ESAPLACEMENT METHOD 8 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 19..SiAND/G SAND/GRAVEL PACK a eshis)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL ft ft: . EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology OSubsidence Control s
ZtC DRILLINGLOalittadradatiteid sheets Ramessars)
OGeothermal(Closed Loop) ❑Tracer FROM TO DEstRWrIoN(color,hardness,soNmdt type,gram du,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft g; .ft (,/ y �(,,
4.Date Well(s)(s)Completed:.r7 3 Well ID# TV`
/D 0 ft s(4" 1,5 l/A'e-
5a.well Location: I G r �f
�-! ft S ft
wn r-t 4zpialk C1C. �/� ft. �� ft 8T'`".GJI fd
9 K��'4�t'�"'"•a g
FactltW/ Name F •
acility ID#(if applicable) rn ; 1 ' / _`1 Y�
ft ft r. a%....O,.d't.�t tna t.s
41 Tina Thrt.s .-Drive ileofusrrivd4 .2571,.a. ft ft. ' JUN 2 L 2023
Physical Address,City,and Zip 2L REMARKS .
,ktilJefso,. . %(orMORK 7802 Infoil?«�:inn Pr•. : r.:g UN
County - Parcel Identification No.(PIN)
CV417.;Oc.r.
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/iong is sufficient) 22 Certifxxtion:
3s°2• •
a',%Y►�sb t/ N qz° 7b3,/f32 ►r W dee .....„
Si of C ' eel Well Con tor to
6.Is(are)the well(s): 21< naneat or ❑Temporary gl,signing - form I hereby certify that the well(s)was(were)constructed in accordance .
with ISA NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing will: ❑Yes or afro copy of this record has been provikd to the well owner.
If this is a repair,fill out blown well construction information and erplab,the nature of the
repair render#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 rmdtiple tryection or non-water supply wells O112:Ywith the same construction,you can
submit one form SUBMITTAL INSTUCTIONS '
9.Total well depth below land surface: • (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if decent(esmnple-3@q5-
and 2@100') construction to the following:
10.Static water level below top of casing: 2 5/J (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. .._ _ 4 (ice) 24b.For Trtiertion 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 Injectiop Control Pmgram,
FOR WATER SUPPLY WELLS ONLY: - 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(Spin) 3 0 Method of test: Blowing-Rig 24e.For Water Sum*de Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
Chlorine 0 completion of well construction to the county health department of the county
.136.Disinfection type: Amont: 6 A OZ.
where constructed.
Form CAT-1 . North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013