GW1--04307_Well Construction - GW1_20230626

W n.r.r,l:V1 1KUl;11UlV ilu+:e Ulm For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: -
BobbyW. Potts
FROM TO , DESCRIPTIoN
Well Contractor Name ft d���'70ft _
NCWC 2028-A =s .• • ft. ft
NC Well Contractor Certification Number ' IS: ACING(for ds> edtidls)ORLDIERfdapplceble)
FROM TO DIAMETER TffiCKNESS MATERIAL
Ferguson's Well and Pump, LLC ft ft in-Company Name - 16. CASING ORTUSING( m_al )
A' FROM To DIAMETER Tg1CKNLi SS MATERIAL
2.Wen Construction Permit#: t9 o.a' — .G O 4O 0 , ft. ft ;n
List all applicable well construction permits e.Cotody,State,Variance,etc.).
f. ft. in
3.Well Use(check well use): • 17.SCREEN
Water Supply Wen: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft . ft in.
❑Agricultural 0Mui..c.. Public
ft❑Geothermal(Heating/Cooling Supply) esideatial Water Supply(single) °1
❑lndustrial/Commercial ❑Residential Water Supply(shared) i&-GROUT. • _
FROM TO MATERIAL i EMPLACEMENT METHOD&AMOUNT
❑Irrigation
Non-Water Supply Well: 0 , ft' 20 f' Concrete Gravity-Flow
ft ft
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 1.9.SAND/GliAVEL PACK;f. bie)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL En:>PLACFammrr METHOD
R ft:
0-Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control ft ft f
20 DRILLI GLt>G:(attidt addi imid s #f ry)
❑Geothermal(Closed Loop) ❑Tracer FROM To DFSCRiPTION(odor,hardness,so&Vrock type,gram she,etc)
❑Geothermal(Heating/Cooling Return ❑Other(explain under#21 Remarks) !G ft /' O .ft C(ot ` �(� .
4.Date Well(s)Completed: $ t3 Well Mir l9VF ft.
t (s7!v0 ft.
`�l a/Y S/r�
Sa Well Location: 7 S _ 0 S 6-Aec- i(e
•
��ronci C ICN.o.-1 1 ft / ft.
�,m--*�
Facility Name 4 Facility l #(if applicable) ft ft �u -� 50v �
rct er1 02G d 't .,: :
�I t�1N� �UKlflirCl Q.•�-= O 7 � _ ft ft
Physical Address,City,and Zip21. s 9, S 2023
—BU,nt^_o)'I b.t- 4(e23 c'.o1307(
County Parcel Identification No.(PIN) r lrti')"' ;11F 7•4 '�s?'t LR:+
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: "
(dwell field,one lat/lo 22.Certification:
( rag is sufficient) �- •
).Se 27to713o 6 Pr N $4A°3S/ /1ST r w r // s4/ 3
of 'fled W n o 17
6 Is(are)the well(s): ermaneat or ❑Temporary By gn g this fonn I hereby certify that the well(stwes(were)constructed in accordance
with 1SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: DYes or o copy of this record has been provided to the well owner.
If this is a repair,fill oru brown well consbuction information and explain the nature of the
repair under#21 remarks section or on the back ofthisfonn. 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: j construction details. You may also attach additional pages if necessary.
FornwUiple injectiarornon-water supply wells ONLY with the sane caasbrrcY'on,you can
submit one fonn SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: ' OS (it) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfdifferett(example- tri,r r'and2@,100') construction to the following: ,
10.Static water Jewel below top of casing: (f{,) Division of Water Quality,Information Processing Unit,
If water level is above'casing,axe•'+" 1617 Marl Service Center,Raleigh,NC 27699-1617
11.Borehole diameter ;i_ 4 (in.) 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 Injectiop Control Prpgram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpin) 6 S Method of test: Blowing-Rig 24c.For Water Snnuly&Injection Wens: 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- SO 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