GW1--04298_Well Construction - GW1_20230626

W LLL I:UNJ1 KUl:11UN MECUM) For Internal Use ONLY:
This form can be used for single or multiple wells • I
1.Well Contractor Information: ,
Bubb W. Potts l4:.WATER•a 1-..i'
Y FROM TO 7 , DESCRD'FION
Well Contractor Name ft. 200 ft I I -
NCWC 2028-A .ft. 5690 ft ,
NC Well Contractor Certification Number 4 OUTER CAS G o ed.i�s)ORI.1NERCrt 61e)
FROM TO DIAMETER THICKNESS MATERIAL
Ferguson's Well and Pump, LLC 0 ft' / 5$ (7 as in t /'5 y ct/
Company Name 16 INNER • G OR TIISING.(3(tuthumal creed-loop)
!r• FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: '0SS —202..3.-D 10:9-.5 ft ft in.
List all applicable well construction permits(Le.County,State,Variance,etc.)
ft ft in.
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft • ft in.
❑Agricultural ❑ pal/Public
OGeothermal(Heating/Cooling Supply) Residential Water Supply(single) ft ft is
❑Industrial/Commercial ❑Residential Water Supply(shared) ,la.GROUT. .• - ,
FROM TO MATERIAL ' EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft 20 ft Concrete Gravity-Flow
Non-Water Supply Well: . ft ft
OMonitoring ❑Recovery
Injection Well: ft ft •
❑Aquifer Recharge ❑Groundwater Remediation .19.SAND/G11AVEL PACKlifatsilcablc)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EtiO'LACEMEI+TPA�THOD ft ft
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control P
ZaDRILLINGloos(attadeaddiCrassl sheets ifa sars)
❑Geothermal(Closed Loop) ❑Tracer PROM To DESCRIPTION(calor,hardness,soil/rock type,punk she,etc.)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 9 ft. ( ).ft `/f (t: U .
..(�
4.Date Well(s)Completed:j/t/fr) .Well IDS (r C9Oft / Yu ft 'a l r'
5a.Well Location:
/VO /53 ft tiji7a c/C
S Q R a ft
t` bj a r
t
Cc .1.41 /ope.Y4l ft. ft.
Facility/Owner Name a Facility UM(if applicable) ft ft •
i"� ;� c
5. 14enc s U)t -NeriJe cnnu(tlQ ct c -79 ft ft rz K' i�a '
Physical Address,City,and Zip 21.REMARKS p q ��
--
kenJer5o i-, RG9oy g au ,7
County Parcel Identification No.(PIN) ,',-
Infrivl C44C l: Cc..•;•t.. um,.
Sb.Latitude and Longitude in degreesminutes/seconds or decimal degrees: U�z�i� '�'
(if well field,one let/long is sufficient) p�+ tit
22.Certification:
3sda/'3St 3 536 /N AD03a '2Ntit g37-t w •
siure o Well n� 3A/12-I
6.Is(are)the well(s): 13Permanent or ['Temporary
By signing this form,I hereby ce►A"rf}'that the well(s)`was(were)constructed in accordmue
with IBA NCAC 02C.0100 or ISA NCAC 02C.0200 Well ContructienStandards and that a
7.Is this a repair to an existing will: ❑Yes or B‘ copy of this record has been provided to the well owner.
If this is a repair,fall out brown well construction Wren:eon and explain the nature of the •
repair winder#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.
For multiple affection or non-water supply wells ONLY Will the same construMioe,you can
submit one form. SUBMITTAL INSTUCTIONS
•
9.Total well depth below land surface: • QS (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths th etent(example-34200'and 2@,100') construction to the following: • '
10.Static water level below top of casing: 5 0 (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing use"+" 161y7 Mall Service Center,Raleigh,NC 27699-1617
1L Borehole diameter. fi` 4 (hr.) . 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 Injectiol Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(pin) y
Method of test: gg
Blowin -RI 24c.For Water Supply&Injectioon Wells: In addition to set 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
--(� where constructed.
•
Form OW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013 _
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