GW1--04318_Well Construction - GW1_20230626

IT L'Lla LAPIN i nut,1'Lin MECUM) For Internal Usc ONLY:
This form can be used for single or multiple wells
1.Nell Contractor Information:
Bobby W. Potts la..WATE ZONES ,• -,;
FROM TO • , DESCRIPTION _
Well Contractor Name ft 200 ft i I.
NCWC 2028-A ft SW ft . - I •
NC Well Contractor Certification Number . ' • 15:OUTERCASING(for> d s)ORLINER(if appl cable)
FROM TO DIAMETER THICKNESS MATERIAL
Ferguson's Well and Pump, LLC 0 it S ft a� in. r'�$ y,�/
IC
Company Name C 16.INNER G OR r T G.(aead eimal closed-loon)
.t FROM TO DIAMFa'FR THICKNESS MATERIAL
2.Well Construction Permit#: A bpa.o.-b Qa 5L( ft. ft in.
List all applicable well construction permits(le.County,State,Variance,etc),
ft ft in.
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM To DIAMETER SLOT SIZE THICKNESS -MATERIAL
❑Agricultural ❑ eipaUPublic ft ft is
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) H ft m.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROTTY.: _
FROM TO MATERIAL s II►(PLACXMKNTMETHOD&AMOUNT
❑irrigation 0 ft 20. fr' Concrete Gravity-Flow
Non-Water Supply Well: ' a tY'
ft. ft
❑Monitoring ❑Recovery
Injection Well: ft. ft
❑AquiferRr.-harge ❑GroundwaterRemediation 19.SAND/GlAVEL'PACifr(ifaeillfpbie)
:Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT M TROD
ft ft
:Aquifer Test ❑Stormwater Drainage ft. ft
[Experimental Technology OSubsidence Control i t
2&DRI LINGLOG(attac oaf:4 W sheets itnecessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DERIt�ON(calor,hardness,soilhoclt type,gram the,etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 6 ft. I O .ft. ( f Q y •
• ft /r/ ft l rc �(,�
4.Date Well(s)Completed: ( /r/i f Well ID# � �� J� ��l/lI�
S ft GS' ft ,A.- /a /C
Sir.Well Location: / C
K.: S4cvcn30rl ►-r, .-FAA, !- C° S f ���ft �'4-1latrlfjt e
Facility/Owner Name Facility ID#(if applicable)
ft. ft 91: .
..-�-�"':Tom'i''0'
I3CA m0SAS ('raLfC.-Lane 5t12.1manron.'2FS.778 ft ft t 1/4.,t4,..-r
Physical Address,City,and Zip 21 REMARKS Q !; 2 ('
33
ta.4,1ennfl - atoR84ZSLII7t f7 �'�' v
County Parcel Identification No.(PIN) iF1� ;:+* • .1 5)r:YF ,rr.;r;Q .,t.'
5b.Latitude and Longitude in degrees/minutes/secondsvi-Q .~(''ngi or decimal degrees:
22.Certi6 'o
(if well field,one latllong is sufficient)
ca ‘(/‘/ --- •
'3S°39_3ri)D6 t, ,N $d.aa3/V, 87$y.1` w r ; ecZa.3____
Si ofCWell Contractor
6.Is(are)the well(s): BPermaneat or ❑Temporary By signing thisfonn I hereby cart that the well(s)'was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or LYttYo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 rensarks section or on the back of this form. 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: INLY
construction details. You may also attach additionalpages if necessary•.
For multiple ugection or non-water supply wells with the same construction,you can
submit fonn SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: o (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths Offered(example-3©200 2(I00) construction to the following:
10.Static water level below top of casing: 60 (ft.) Division of Water Quality,Information Processing Unit,
If water levells above casing,use"+" 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. . _ 4 (in.) 24b. For Iniection WeRse 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 InjectiogtControl Prpgram,
FOR WATER SUPPLY'WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(spin) a Method of test: Blowing-Rig 24c.For Water&tonic&Injection 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 �� OZ. completion of well construction to the county health department of the county
where constructed.
Form GIAT--1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013