GW1--04311_Well Construction - GW1_20230626

vv MAUL l.1,1111►711(U l.1 IU1N1 KLt,(:UKU For Internal Use ONLY:
This form can be used for single or multiple wells I
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1.Well Contractor Information:
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Bobby W. Potts , . FROM TO
racsagnmoN
Well Contractor Name ft. ft
NCWC 2028-A I ft ft 1 I • •
NC Well Contractor Certification Number • IS:OMER CASING(forim edws8s)ORLINER(ifap�able)
. FROMFerguson's Well and Pump, LLC ' tD ft T ye ft Dr gf is M C.
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Company Name 16.INNER CASING ORTUEIlNG.(tun thuail dosed-bap)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 2.0(8 "' b D o7C.1 ft. • ft. m.
List all applicable well construction petrtrits(ie.Cotmty,State,Variance,etc.), •
f. ft in
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3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft ft • in.
❑Agricultural DMuni ' lc
OGeothermal(Heating/Cooling Supply) esi Water Supply(single) ft ft is ,
❑Industrial/Cominercial ❑Residential Water Supply(shared) •18'(RZUiIT. • - .
FROM TO MATERIAL ' EMPLACEMENTMLRHOD dt AMOUNT
❑lmgation 0 ft 20 ft Concrete Gravity-Flow
Non-Water Supply Well: ft ft •
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑GroundwaterRemediation L9..SA D/GIIAV,EL'PACE:#if abe) .. •
PROM TO MATERIAL Et14PLACEMENTMETHOD
❑Aquifer Storage and Recovery O Salinity Barrier ft ft: -
❑Aquifer Test CIStormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control .0 t
-.28:DRILLING LOGlittaidiidifdlirmalsheets ifaecessary)
OGe othermal(Closed Loop) ❑Trader FROM TO DESLItIPTION(color,hardness,solltroch type,tram She,etc)
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) O ft. /b .ft 1' /a"
ft ft /y
4.Date Well(s)Completed:0/R3 Well ID# a
�solo��
ft et2 ft r/C
5a.Well Location: n r
^� yA 2`!Sft ��U/Ito
VQnaoCi• iituritt` ft. ft
Facility/Owner Name Facility ID#(if applicable) 11..—:
r F'i C
ii 'Makin tL s Cove 42d . Le i. teat ,.2.R,11 rt. ft as'. r'a, �-/.
Physical Address,City,and Zip 2L REMARKS J J N 9, ry 2 0 7 3
tr1Ct71'r1b C. . 1.7to a'g S�[e a.
County el Identification No.(PIN) lllkIcir.?i:t£"r1 t"t':>:'=yra i:J l:t:w
Di Ilk"~ ;
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22
(dwell field,one 1st/long is sufficient)
Certification:
35' 93(346ye(('‘N 'A° 30107/WVr' .6 kb/21_
w v 0
Signature of eel Well Contractor
6.Is(are)the well(s): 13 ermanent or ❑Temporary By Sigrm:g this forms I hereby cent,that the well(s)owas(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well ConstructionSow:dards and that a
7.Is this a repair to an existing well: ❑Yes or o copy of this record has been provtekd to the well owner.
If this is a repair,fill out blown well constructionWfonnation and explain 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: / construction details. You may also attach additional pages if necessary.
For multiple byectiar ornan-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: • A yS (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
. For multiple wells list all depths iVet:Jen:int(example-3(t r200'and2@100') construction to the following:
/a (ft.) Division of WaterProcessing Unit,
10.Static waterbwel below top of casing: Quality,Information
If waterlevet is above'casing,use"+" 1617 Man Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. -,w 6 (n-). 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 Injectio*Control Prpgram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
Blowing-Rig 24c.For Water Sup &Infection Well
13a.Yield(gpm) �D Method of test: gg � s: 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: 30 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 Quali I Revised Jan.2013 ,