GW1--06326_Well Construction - GW1_20230927

W MALL ILL/110 11tU L 11U1V•Kti1CUK1U For Internal Use ONLY:
This form can be used for single or multiple wells '
1.Well Conhactor Information: '
Bobby.W. Potts - 14.W4TERZONES ' • i. i
Y FROM TO r DESCRIPTION
Well Contractor Name ft /5Q ft I • ,
NCWC 2028 A• t` p' 0 ft 1 1
NC Well Contractor Certification Number 15.O1y ER ING(formnitisased'wells)OR LINER(d )
FROM TO DIAMETERI THICKNESS MATERIAL
•
Ferguson's Well and Pump, LLC d ft s'r ft. . G tA5 in . 21611 s' tr.$7),22/ •
•
Company Name • . 16.INNER CASING ORTIJHING.(eeg 0 hermaldared-leap)
FROM TO DIAMETER, THICKNESS• MATERIAL
2.Well Construction Permit#: 0Oa3 - 666p6 ft ft in.
List all applicable well construction permits(re.Cow#y,State,Yarlmtce,etc.)
ft. ft. I' in.
3.Well Use(check well use): '
17.SCREEN I.
Water Supply Well: FROM TO DIAMETER!, SLOT SIZE , THICKNESS MATERIAL
❑Agricultural ❑ pal/Public ft ft in
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft. hi 1 • •
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT -
FROM TO MATERIAL ' EMPLACEMENT METHOD&AMOUNT
❑Irrigation , 0 ft 20 ft Concrete Gravity-Flow
Non-Water Supply Well: '
❑Monitoring ❑Recovery ft ft
Injection Well: ft. . ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK Cd makable)
FROM TO MATERIAL • ' EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier R ft • I" ' •
❑Aquifer Test ❑Stormwater Drainage •
ft ft
°Experimental Technology OSubsidence Control /'.
20.DRILLING LOG(attach additional sheets ifnecessary)
. .❑Geothermal(Closed Loop) ❑Tracer : PROM .TO ' DESCRIPTION color,hardness,solUrock type,grain she,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) -0 ft 3� .ft C(Q`I
p ft e ft r
4.Date Well(s)Completed: Well ID# 3o yv SAu
you Syft. ,, . A id'e
'5a.Well Location: •
C, ► S It Ill SY r OS f` . &w,tic'
y lcx 6 ' _
.Facility/OwnerRame Facility ID#(if applicable) ft ft -•
10(5 5. r e__reGK. 1-tce54cr• o18708 ft: - ft ;, o L. } r.�...,
Physical Address,City,and Zip 2L REMARKS S E P r 7 2023
oin b $Ia 7R 7 8��7 C
County P• arcel Identification No.(PIN) IR Jr(... !�f ('r .:::. t= :3 UUR::a
C°:':-saJ,-1:
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one tat/long is sufficient)
3s°361.y4 3att f it y(► 131 r g0Sf / W • �� $ �1 a' .
Signature of ad V r Da
6.Is(are)the well(s): QPermauent or ❑Temporary
By si . this form,I hereby certify thiat,the wells)was(were)constructed to accordance
with I5A 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 ENo copy of this record has been pmviabd toihe well owner.
Ifthis is a repair,fill out brown well construction information and explain the nature of the 1.
repair order#2l 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 injection or non-water supply wells ONLY with the sane construction,you can
submit ewefoen SUBMITTAL INSTUGTIONs ,
9.Total well depth below land surface: !7',0 S (ft.) 24a. For All Wells: Submit this;form within 30 days.of completion of well
For multiple wells list all depths ifefifferent(example-3@200 and 2@I00') construction to the following:
10.Static water level below top of casing: Cs?V (ft) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole dieter. •v._ ( (in.) 24b.kor Infection Wells: In additi�n to sen am ding;the'foma to'thetadiltess in 24a
above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Rotary construction to the fo_lloaing: 1 '•
.- (i.e.auger,rotary,cable,direct push,etc.) i
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 99-1636
13a.Yield(gpm) )0 ' Method of test Blowing-Rig 24c.For Water Sunnis:&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 C-W-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013 •