GW1--04304_Well Construction - GW1_20230626

vv mkt',l unm 11tU 1;11UIN KELAJ.UJ ' N' For Internal Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information:
Bobby W. Potts
FROM TO .- , DESCRIPTION
Well Contractor Name . ft (A 0 ft.
NCWC 2028-A ft. ft - I • •
NC Well Contractor Certification Number . ' 15:OUTERCAS1NG(for Th sofwe ls)ORLINER(if appSalrle) •
FROM TO • • DIAMETER THICKNESS MATERIAL
Ferguson's Well and Pump, LLC ' a" 6 r 25in- /�
' //�S P�'cSp2 2/
Company Name 16.INNER G OR TUBINGOieathanal dosed-lisp)
R • v PROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 2 CD 2-3 -- O.O I $D ft ft, in.
list all applicable well construction pertrrits(i.e.County,State,Variance,etc). .
f. ft. m
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3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SUE THICKNESS MATERIAL
•❑ cultural ft ft ha.❑Muni ' Public
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft is
❑lndustrial/Commercial ❑Residential Water Supply(shared) It-GRQUT.. • -
FROM TO MATERIAL " E PLACEMENTMEmon S AMOUNT
❑imgahan ft 20 ft. Concrete Gravity-Flow
Flow
Non-Water Supply
ply Well: . ft ft A
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑GroundwaterRemediation` 19.SAND/GRAVELPACK-Ofispl6*Mb) . •
OAquifer Storage and Recovery ❑Salinity Barrier PROM TO MATERIAL EMPLACEMENT METHOD
ft ft:
❑Aquifer Test ❑Stomiwater Drainage ft ft .
❑Experimental Technology ❑Subsidence Control e
20.DRILLINGLOG(attasi actin sheetsifbeasnry)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,sotl/roctt type,gram site,etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) C) ft 1/5 ft a &Y .
4.Date Well(s)Completed /3�•2 3 Well>D# (�S ft /6 ft See �
Sa.Wen Location: ea G �'eyt5le
c%
/r
bhh l4 a1� ft 7Vsft . .w;°rf
Faciii /OwnerN ft. ft C.S y.-...F—.�z.j�,t ply r�F*y�
tY / / In•,. Facility (if applicable) ft. ft " -- '..^.``•'',""-4 °?7 t1"•-- ''
6U r.Jl(c)Z LArpz = Hf &ior Q&7j5, , ft. ft JUN W ZOZ3
Physical Address,City,and Zip 21 REMARKS
UV"C6m h-e: g10,4 (4 35L/b 1 Ink;-r;,:a.�:n ^- / `:::3 tiFfh-A
County - Parcel Identification No.(PIN) J','- y2.
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5b.Latitude and.Longitude in degrees/minutes/seconds or decimal degrees: 22.Certificati n •
(dwell field,one Wong is sufficient)
%S5/ 0°Z17/fA N tyR.°3r ' ' / " w 4, /,\3t/�
,..1/1//a_3__
Signature o ed Well Contractor
6.Is(arc)the well(s): ermaneat or ❑Temporary By signingthis fonn,T hereby certiAdna the well(s)`was(were)constructed in accordance
with 1SANCAC 02C.0100 or 1SANCAC 02C.0200 Well Construe:UmStandards and that a
7.Is this a repair to an existing well: ❑Yes or l f o copy of this record has been provided to the well owner.
Ifihis is a reps fill out brown well construction afonnation andexplam the nature of the •
repair under#21 remarks section or on the back of thisform 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: 1VL construction details. You may also attach additional pages if necessary.
For multiple ngectiaror non-water sirpply wells O T with the same construction,ution,you can
submit one form /r SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 7J (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For madtiple wells list all depths tf fer»d(example-3@2200'and 2(4100) construction to the following:
10.Static water level below top of casing: 0 (ft.) Division of Water Quality,Information Processing Unit,
If water levefis abave'casing,use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. :i_ : 6 _(in.). 24b.For Injection Wells: In addition to sending the form to the address in 24a
Rotary 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 Injectitst Control Prpgram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(pin) I2N Method of test: gg
BIowin -RI 24c.For Water Simnly&Injection Wells: In addition to sending
the form to
the address(es) above, also submit one copy of this form within 30 days of
13b Disinfection type: Chlorine Amount 60 oz. completion of well construction to the ccounty health department of the county ,
where constructed. _
Form OW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013 .