GW1--04325_Well Construction - GW1_20230626

w LLL a-Lyn a 1 Kul,1 JUN MECUM( ) For Internal Use ONLY:
This form can be used for single or multiple wells
I
1.Well Contractor Information:
.
Bobby W. Potts 14.WATER-ZONES;: -
FROM TO • , DFSCRIPTXON
Well Contractor Name ft ft
NCWC 2028-A +t. ft
NC Well Contractor Certification Number 1S.OITIERCASING(for m edWells)ORLINER(dangsaible)
. FROM TO DIAMETER THICKNESS MATERIAL
Ferguson's Well and Pump, LLC 0 f e0 f 6,,Z S in. IV,,/g5 j 3c cpg?, /
Company Name 16.INNER CASING ORTUSING:(geothermal dosed-loop)
R •� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 2 62A ^ 6 C)`q 63 . ft ft in.
List all applicable well construction permits(i.e.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
DAgricultural ❑ ltc ftit ft in.
(Heating/Cooling Supply) P1Residentr ater Supply(single) ft m
❑Industrial/Commercial ❑Residential Water Supply(shared) 10..GRMUT.. - ,
FROM TO MATERIAL • EMPLACEMENT METHOD&AMOUNT
❑Imeat<on Supply Well: 0 ft 20 ft Concrete Gravity-Flow
Non-Water,Sa
ft ft
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19..SM D/Gl WEL PACKtifannliwble) .
❑Aquifer Storage and Recovery ❑Salmi Barrier FROM TO MATERIAL ` EN�LACERffiSTaiErxoD
tY er ft. ft -
❑Aquifer Test ❑Starmwater Drainage
ft.
❑Experimental Technology ❑Subsidence Control . ft e
ZL DRR LII!G LOGliderdi ad anal elm ifneorssarsl
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIF/ION(color,hardness,soll/rodt type,gram die,etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) Q ft z(/ .ft. Clay �/ .
4.Date Well(s)Completed: 3 � a) Well I 20 tc 35 ft 5Q nt�s/77t
( D# 35 ft so ft Ae0r/`ec A
Sa.Well Location: ft. ��t r�
�5 {,Q 2tt'SS Ne,G1L9ct,� �� ft. 7U ft t awl c
Facility/Owner Name Facility ID#(if applicable) - ft. ft
121 Se-(c0 tO( =f�f 1v,e rNicwt} i Ze7I1 ft ft b�" L;I, fir:L..)j'
Physical Address,City,and Zip
// /� 2LREMARKS J�IrJ c) r 2023
13u.YlrCYrtihP • 6 __()S Iu galaw0 l .d
County - Parcel Identification No.(PIN) ink:M t ic^il Prc;r,zo::'7 kin
Sb.Latitude and •�L�
Longitude in degrees/nanntes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
•
3S°l{Q •
/37,77-7Y N ''A 3 7'V2, 500 Ir w atr43—
� Signature of . eel ell ntractor
6.Is(are)the well(s): L�'Permanent or ❑Temporary By signing this form,I herebythat the ireAs
wit* (pwas(were)constructed in accordance
with 1SA NCAC 02C.0100 or 15A NCAC 02C.0200 Well ConstnrcfenStandards and that a
7.Is this a repair to an existing well: ❑Yes or Wet 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 wider#21 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
8.Number of wells constructed: / construction details. You may also attach additional pages if necessary.
For multiple bgecti n or non-water supply wells ONLY with the same carom,you can
submit aiefoms SUBMITTAL INSTUCTIONS •
9.Total well depth below land surface: . 7/)c (g) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiffereut(example-3@200'and2@l00') 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,sire"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. i- _ (0' (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 Injection Control Prpgram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
I
13a Yield(gpm) "— Method of est: Blowing-Rig 24c.For Water Supply&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: 0 OZ. completion of well construction to I 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 •