GW1--04321_Well Construction - GW1_20230626

vv r,..■.kAirto I.AU t.,I IU1' KI1 C.UKU For Internal Use ONLY: •
This form can be used for single or multiple wells _ I
1.Well Contractor Information:
Bobby Al. POttS 14.WAT •TO
ZZ ONES'• •....momDi mioN
Well Contractor Name ft .2 X0 ft I • .
NCWC 2028-A .- -ft gro ft • "
NC Well Contractor Certification Number , 15 Q[JTEAL�ASJNG(for stidfi:caded�eella)ORI.1NI$R(idap st6le)
FROM TO DIAMETER THICKNESS MATERIAL
Ferguson's Well and Pump, LLC d ft rgi. ft (i r l " zarizi Pc'ccp,2i
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Company Name 16.INNER CASING ORTUBING.dermal dosed )
t- • el „eN p FROM .TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit it: • • a Of- —6'v'1 1, ft ft m.
List all applicable well construction permits(Le.Cowry,State,Variance etc).
ft ft ire.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: . . FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft - ft is
❑Agricultural ❑Manic" lic
OGeothermal(Heating/Cooling Supply) iesE7R dential Water Supply(single) it. ft. a'' ,
❑Industrial/Commercial ❑Residential Water Supply(shared) 18-GRO13T..
FROM TO MATERIAL . EMPLACI MENTMETHOD&AMOUNT
❑Irrigation 0 ft 20 ft' Concrete Gravity-Flow
Non-Water Supply Well: ft ft A
❑Monitoring ❑Recovery
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/G12AVEL•PACKtifitsiiicable) .. '
FROM TO MATERIAL EMPLACEMENT METHOD '
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft: - .
0-Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control
20:DRILLINGLOG(attath ad6tioeal sheets ifbeossar9)
❑Geothermal(Closed Loop) OTracer FROM ft TOO t DFSCRU'•ION(c$er hardness,sou/rock type,gram sae,etc.)❑G eothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ( C l/ y .
2 ft G ft
4.Date We Completed: p?> Well 1D# r�S S r n s G
Sa.Well Location: ft sus ft t
_
efst:•� i k 6n4 ft. ft g
tj - Facility TDB(if applicable) ft ft -"•#� ^i+ h
Faciii /Owner Name I.
1 b.9eA-a 2dA Eta;ruiew g.S 13o - ft. ft JUN 2 (i LLIL3
Physical Address,City,and Zip
2L REMARKS
aLon covnbti - O{(o%5a7 $631 tn(gc l4�i-rC^: >:::�L'r,�
County Parcel Identification No.(PIN) c,32 "' -
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56.Latitude and Longitude in degrees/minutes/se ands or decimal degrees:
(ifwell field,one tat/twig 22.Certifieati
ng is sufficient) ,
15e)/ '6 3/_%Ce ' fA Y eerg.z8 'r W ,�( k� /23/2
3
Signature of�►-.t-,Well Contractor
6.Is(are)the well(s): CdPermancut or ❑Temporary signing this I here that the we c BY �r8 .form, by cm* A(s"cos(were) ted in accordance
with ISA NCAC 02C.0100 or 1SANCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or CENa copy of this record has been provlckd to the well owner.
Ifthis is a repair,fill out lmown well construction irrformalion and explain the nctme of the
repair yonder#2I remarks 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
S.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple bgectim or non-water supply wells ONLY with the same construction,you can
subrrct onefam SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: .50,S (tit) 24a. For All Wells: Submit this,form within 30 days of completion of well
For maniple wells list all depths if different(example-3@200''and 2@100') construction to the following:
10.Static water level below top of casing: ii.O (ft) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Matz Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. :i_ _ 6 (in.) 24b.For Injection 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 Injectiot Control Provgram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) / Method of test: Blowing-Rig 24c.For Water Smith&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
•136 Disinfection type: Chlorine Amount S 17 oz. completion of well construction to the county health department of the county .
where constructed.
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Form COW--I North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013 _