GW1--04317_Well Construction - GW1_20230626

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For Internal Use ONLY: _
This form can be used for single of multiple wells
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1.Well Contractor Information:
Bobby W. Potts .14.WATER•z 3NES4 •...... .
FROM TO '- , DESCRIPTION
Well Contractor Name ft ft
NCWC 2028-A ft • ft . ' I 1 .
NC Well Contractor Certification Number , . 1S:OUTER CASING/for adfi ed.wdls)ORLINER(dapgable)
Ferguson's Well and Pump, LLC ' . FROM
it Tu DIAMETER THICKNESS MATERIAL
•
R.
• 2,/(,/.2S /7UcSD42./
Company Name 16.INNER CASING OR AS G facitisminal dosed-bon)
FROM TO DIAMETERTHICKNESS MATERIAL
2.Well Construction Permit#: : : L(JI ""•0063.7 ft " ' ft in.List all applicable well conshvction permits(i.e.County,State,Variance,etc.).
R ft in.
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft - ft M.
❑Agricultural ❑ rpal/Public
❑Geothermal(Heating/Cooling Supply) ffResidential Water Supply(single) ft ft in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18-C>RMUT.. . =. . . -
FROM TO MATERIAL EMPLACEMENT METHOD 8 AMOUNT
❑lmgation 0 ft. 20 ft Concrete Gravity-Flow
Non-Water Supply Well: ,
ft ft
❑Monitoring ❑Recovery
Injection Well: ft. ft
❑Aquifer Recharge ❑GrotmdwaterRemediation 19.SVID/GGRAVELPACKtifapaDetble) .. •
❑A etand FROM TO MATERIAL EMPLACEMENT METHOD
quif Storage very _ ❑Salinity Barrier ft ' •
0-Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control t,
•20:DRIT:LD1G LOSftittadridilframi sheets if niters)
• ❑Geothermal(Closed Loop) ❑Tracer FROM TO' ' ,DESCRIPTION(color,hardness,son/rock type,erna she,etc)
❑Geothermal(Heating/Coolin�g• -Return) ❑Other(explain under#21 Remarlcs) 6 ft to .ft e/at`. •
; : : '
�//s/a3 Well ID# �/JJJ ' rt JrA ft 76 g ft . kY.f w/t C
�ib-.74- `° Q 66..1'J{$! et. . ft. ft. .
Facility/Owner Name _ Facility ID#(if applicable) _
O1I n(ay nn (/S `f d�{/'(Jt a•�t.) e3 2 ft. ft ,.:�N...,,'ti 9 s at,-.....:
Physical Address,City,and ip
JU• N
REMARKS I �I Zll
Unt"�n�6a -ptat5o?G3a14omeoc) l� J
County • Parcel Identification No.(PIN)
iflfi+ii'Fr,,aC.11:fir{;-^F.A4Y.f.'`el Um
Longitude in d - �'A '
Sb.Latitude and egreesinrinutes/seconds_or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
3S°.30 5S,y'c�v yr f N is D/�`!Do r 762. t w �.- L� � .�
Is // Signature of eel Well Contractor to
6. (are)thewell(s): ( meanest or ❑Temporary
By segrrtreg this form,I hereby certify that the well(s)ervas(were)constructed in accordance
7.Is this a repair to an existing well: OYes or CBNo with of hisre�.0100 or Ivlt dto O2C well 200own Well Cosrsauctia,Standards and that a
If this is a repair,fill out known well construction bJomralton and explain the natroe.ofthe •
provi�dto the owner
repair:eider#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
8.Number of wens constructed: / 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.
For multiple fgectron or non-water supply wells ONLY with the same cansbudion,you can
sub»ut one form SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: • 7(S ((it) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tf different(ern»plc-3@200'and 2Q100') construction to the following:
10.Static water level below top of casing: (ft) Division of Water Quality,Information Processing Unit,
If water level Is above casing,use"+" 161'1 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: ; _ 6 (m.) • 24b.For Infection Wells: In addition to sending the form to the address in 24a
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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 Injectimt Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield m Blowing-Rig 24c.For Water Supply&Injection Wells: In addition to sendingthe form to
(gp ) method of test: g g
the address(es) above, also submit one copy of this form within 30 days of
•13b Disinfection type: Chlorine Annount �d oz. completion of well construction to the county 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