GW1--04315_Well Construction - GW1_20230626

ynr,■,a,t,V1\011eU(.1IVA 1(1lA;V1UJ For Internal Use ONLY:
This form can be used for single or multiple wells I
•a
1.Well Contractor Information:
Bobby W. Potts 14.WATlZOpl&S.
FROM TO DESCRIPTION
Well Contractor Name ft LS 70 ft
NCWC 2028-A -. .ft. ft .
-NC Well Contraetor Certification Number . • • 1S:OUTER CAS1NG f$ d.wells)OR LINER Ofapplicable)
Ferguson's Well and Pump, LLC ' Q ft TO DIAMETER TffiCIrISESS MATERIAL
l e 2.5 216r/ PO'dPeeZi
Company NameCASING•
16.INNER OR"TUBING:(tjeut>htrm al dased-1oop)
PROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: "" • .ZU.Z Z- - 6 G L/C?lO ft " ft hi.
List all applicable well construction permits l e.County,Stale,Variance,etc.). -
f. ft in
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
• ft • ft is
❑Agricultural ❑ cipal/Public
•
❑Geothermal(Heating/Cooling Supply) 6Residential Water Supply(single) ft ft in .
❑Industrial/Commercial ❑Residential Water Supply(shared) 11-(RL°CT• • - -
FROM TO MATERIAL " EMPLACEMEIFT METHOD&AMOUNT
Olrrigation Ppl9 Well:
0 , ft. .20 ft' Concrete Gravity-Flow
Non-Water
ft ft
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Resnediation '19.ReINII/GliAVEL PACK.tif sandiahle) •
FROM TO MATERIAL - EMPLACEMENT METHOD
❑Aquifer Storage and Recovery _ ❑Salinity Barrier ft. ft' -
❑Aguifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control -. r .
,..28.DRILLPiGLOG(attad addilatal sheets ifnecessat9)
❑Geothermal(Closed Loop) OTracer FROM TO DESORPTION(color,hardness,solllrock Wm,grain she,etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarics) 0 ft So -ft (&
�''� ft /' ft CVorr
4.Date Wells)Completed��� a 3 Well ID# 5 5 ft l� ft o L/C
na.Well Location: ((( (e
73 705 ft . ��
I i•{'-P'ialy Z 10;/Sf3n./4 d ft. ft
Facility/Owner Na gfe Facility lD#(if applicable) ft ft _
//a Pn t j,,-//e 1-l' -Dr #ur1/it ) 1 R 13C) ft ft. . - ...,,a,..a v b..
Pt ysical Address,City,and Zip .
21.REMARKS • J N 2, 2023
• Au0e_tim6i . '169613/6 g 84
County Parcel Identification No.(PIN) ?r�r"c
Longitude in degrees/minutes/secondstltl`v+37.t'r c^,l L tza
ngi or decimal degrees: 22.Certification:
S 3�
5b.Latitude and Lo
(if well field,one lat/long is sufficient)
3S°a71D�3/s( N $2°3StVS; / PIA 1, W
Signature of "fled Well ntracto c.Da
;1'77 -3---
6.Is(are)the weII(s): ertoancut or ❑Temporary By signing this form,1 fib,cm*that the wells, was(were)constructed in accordance
with 1SANCAC 02C.0100 or 1SANCAC 02C.0200Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or o copy of thus record has been provided to the well owner.
If this is a repair,fill out lamwn well construction information and esplairn the hatted of the
repair under#21 remarks section or on the back of thisform 23.Site diagram or additional well details:
8.Number of wells constructed: /1 You may use the back of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
Fornur<ltiple injection or non-water supply wells ONLY with the same consbnctian,you emu -
submit one form. SUBMITTAL INSTUCTIONS •
9.Total well depth below land surface: • 74. >t-' (D,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iftkferent(example-3 'and 2@100D construction to the following:
10.Static water keel below top of casing: /60 (ft) Division of Water Quality,Information Processing Unit,
If water level-is above,casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter.4. _ 6 (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 Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(pin) Method of test: Blowing-Rig 24c.For Water Simply&Infection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
-IS.Disinfection type: Chlorine Amount: ('/' OZ. completion of well construction to the county health department of the county
---�{ where constructed.
Form.3W-I - North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013