GW1--04324_Well Construction - GW1_20230626

w RAJ',(.-Una 1 ltU l:1 lU1V .KR CLIKB For Internal Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information:
Bobby W. Potts FROMAT TDO�. , DESCRIPTION
Well Contractor Name ft C�i 9v ft I -
.
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NCWC 2028-A 'ft o2Z0 ft . - •
NCWellContraetotCextificationNumber •
, 15:OlTfERCASINGs(for s)OR LINER(i ap�ficable)
. FROM TO DIAMETER THICKNESS MATERIAL
Ferguson's Well and Pump, LLC S ' © ft Sy ft C cAS ill2/It/25 firc517,2/
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Company Name 16.INNER CASING OR TUBING(nsithennal dosed-loop)
A FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: V c s " [) 0 5 7e� ft ft in.
List all applicable well construction permits(i.e.County,State,Variance,etc.),
f. ft in
3.Well Use(check well use): 17 SCREEN
W apply Well: FROM TO DIAMETER SLOW SIZE THICKNESS MATERIAL
ft • ft in.
Agricultural ❑ lic
OGeothermal(Heating/Cooling Supply) esi�ater Supply(single) ft ft in
❑Industtial/Commercial OResidential Water Supply(shared) I&.GRm T.. .
FROM" TO _MATERIAL s EMPLACEME TTMETHOD B.AMOUNT
❑brigation 0 ft. 20 ft. Concrete Gravity-Flow
Non-Water Supply Well: f
ft ft
OMonitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19..SAND/G16VELPACKtifam cable)
FROM TO MATERIAL EMPLACEMENT METHOD
['Aquifer Storage and Recovery _ ❑Salinity Barrier ft. ft: .. •
❑Aquifer Test ❑Stormwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control i t,
28:DRILLINGLOGOiltickadiiittimalsheets# rs)
❑Geothermal(Closed Loup) OTracer FROM TO DERRIP1TON(color,hardness,sotttrock type,gram she,etc)
OGeothermal(Heating/Cooling Return)rr�� ❑Other(explain under#21 Remarks) D ft 30 St V .
SY
4.Date Well(s)Completed:$ 9 Well ID# Cf5 ft. 3 7 ft. e
Sa Well Location: �. ft �s ft
AA; /; „
��yy ztl ell MemnonS ft ft
Facility/Owner Name _ Facility lD#(if applicable) ft ft 3.; % 'q.�,y i '' --1`
I'Lr.,e`_.,�.ni lift
"781 Sc�,k1.. Ct n K LL1 _ st-c.r - ft. ft Physical Address,City,and Zip We 21.REMARIKS I 1 V ti G 2023
-----t>comps)be . 75 7$20.also
tyCo Parcel Identification No.(PIN) Ir t;�;i,�:� 7.r::r .:: .'sg u t
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Cerhfrcati n:
(dwell onelat/lorag is sufficient)fficient) •
3sO)t 23 V/ ' N 5,t D' eqa Sif�1.r W lif ita
�_� Signature of Bed WetP
Aq(21703--
6.Is(art)the well(s): Yd!'eflnanent or ❑Temporary By signing form,I hereby certifr that the well(s)%was(were)cauhucted in accordance
with ISA NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing wet: ❑Yes or o copy ethic record has been provided to the well owner.
If this is a repair,fill out known well construction bformation and explain the nature of the
repair under#2I remarks section or on the back of this fonn. 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 tnyectionor non-water.supply wells ONLY with the same construction,you can
submit aaef� SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 0 s (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
ifd
For multiple wells list all depths Brent(example-3@t20 'and 22@100) construction to the following: '
10.Static water level below top of casing: 2.0 (f(,) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Matz Service Center,Raleigh,NC 27699-1617
1L Borehole diameter... °= _ 4 (in.) 24b.For Inieetion Welts: 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
- 24c.For Water Sunni,&Injection Wells: In addition to sending Yield(gpm) �Vn Blowing-Rig of test: g g the form to
the address(es) above, also submit one copy of this form within 30 days of
•136 Disinfection type: Chlorine Amount: oZ completion of well construction toll the county health department of the county .
G �J where constructed. _
Form C W-I • North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013
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