GW1--04310_Well Construction - GW1_20230626

yrr+a.a.+IL-voila 1nut.iIlan itrrt.uttu For Internal Use ONLY: •
This form can be used for single or multiple wells
1.Nell Contractor Information:
Bobby W. Potts 14:.WATER• TES;:
PROM TO • , bFSCI Wf1ON -
Well Contractor Name - ft •./O ft
•
NCWC 2028-A ft ( ft I •
•
NC Well Contactor Certification Number • • • .lS:OUTERCASING di. ed.wells)ORLINER(ifappraNe)
FROM TO DIAMETER THICKNESS MATERIAL
Ferguson's Well and Pump, LLC ' 0 ft 44 ft 6r �-2 4,/AY .PeCS M2/
•
Company Name . 16.INNER CASING ORTUBING.(aentbermal dased-loup)
R PROM TO
ft ft. DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: • 3 b.b a 0 ;a'
List all applicable well canstruclon pemdts(i.e.Cowry,State,Variance,etc.).
. ft ft in.
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
it ft in.
❑Agricultural ❑ • rpal/Public
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft is
❑lndustrial/Commercial ❑Residential Water Supply(shared) ,18,(RtQ[JT..
FROM TO MATERIAL '''FMPLACEMENTMEMOD&AMOUNT
❑In Ware spry Well: 0 ft 20 ft Concrete Gravity-Flow
Non-Water ft ft. '
❑Monitoring :Recovery .
Injection Well: ft ft
❑Aquifer Recharge 0 Groundwater Remediation 19.SVID/G1LWEL•PACi(ff is) .. •
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL ft ft:. _ EMPLACEatgNTrIOD
:Aquifer Test ❑Stomiwater Drainage ft ft
DExpelimental Technology ❑Subsidence Control r
,.241:DRILLING LOtr(4taa iiadilifiiiii sheets ifaeeessary)
❑Geothermal(Closed Loop) ❑Tracer PROM TO DFS(.'EtIPTI (odor,hardness,son/rock type,train d2e,etc.)
❑Geothermal(Heating/Cooling Return ❑Other(explain under 421 Remarks) 0 ft //�S It C(a y
4.Date Well(s)Completed: A �3 Well D?q -
(�>•ft. (O U ft 5
&oft 65' ft (-e o< <
n Well Location: or ft 38 S ft . 6/12(�, -
• •'inert.' ii(Q h�/..,e•— ft. ft •
.:-
FacilityiOwncrN V _ F• acility ID#(if applicable) R ft
t83-ii8 vex-bb/f ii L.' e k-,;g7. ft ft : :,.: ./a ' L
Physical Address,City.and Zip IL REMARKS . . i U r rti J 2023
ncool6�� 9 76a.S�317yodva rti
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude m d - •r .;i��='ngi degrees/minutes/seconds or decimal degrees: 22.Certi@cation:
(if well field,one lat/long is sufficient)
rr
3c't(D `gy7AT6 .N �'Aa9/ /1 6 8' w
of " ed Well Contract° to
6.Is(are)the well(s): cit ermaaent or OTemporaay By signing this form,I hereby ee>kf,that the wel(s)reas(were)constructed in accordance
7.Is this a repair to an existing well: ❑Yes or copy of this record .0100 ISA duo the 02C well own200 r.W Cond>vcdar Sim dmdr and that a
If this is a repair,fill out known well contbvction ofornration and explain the nature of the •
provided to owner
repair wider#21 remarks sechonor 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
S.Number of wells constructed: Yconstruction details. You may also attach additional pages if necessary.
Forrmdbple byecticn or non-water supply wells ONL with the same construction,you car
submit one form SUBIlIITPAL INSTUCTIONS
9.Total well depth below land surface • O'. 0 go 24a. For MI Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths(different(example-3( 00'and 2©100') • ' construction to the following:
10.Static water level below top of casing: 4(0 (ft) Division of Water Quality,Information Processing Unit,
/water level-is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699.1617 .
11.Borehole diameter. :P_ 4 (in.) 24b.For Infection Wells: In addition to sending the tbrm 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 Injection Control Prpgram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(Spa) / Method of tear Blowing-Rig 24c.For Water Snook&Infection 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 3•d OZ. completion of well construction to the county health department of the county
where constructed.
Form C W-1 - North Carolina Department of Environment and Natural Resources-Division of Water Quality . j Revised Jan.2013