GW1--06331_Well Construction - GW1_20230927

Y7 L`LL 1.wrio 1 nut,11U1it itztA KU For Internal Use ONLY:
This form can be used for single or multiple wells, /` /lt r( 1 .
1.Well Contractor Information: lam" ( '
Bobo W. Potts 14.WATER ZO 4ESs ;
Y FROM TO • , DESCRIPTION
Well Contractor Name • ft )7 S "ft - I I .
NCWC 2028-A ft Z?0 "ft. p
IS.OUTER CASING Well Contractor Certification Number dls)ORLIIYER(ifhie)
FROM r TO DIAMETER 1 THICKNESS MATERIAL
Ferguson's Well and Pump, LLC t /
• c� cAsnvX �Sl. 2/(�,25' ecjp,2ZJ
Company Name • 16.INNER G ORTl l G(animal dosed-loop) . .
(3 FROM TO DIAMETER ' THICKNESS" MATERIAL
2.Well Construetion Permit#: • "Oc — D 0 O.5 D : ft ft ; in. • -
List all applicable weRcanstruction peniats(r.c.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 •❑��M�uni'•paUPublic ft ft. •in.
[]Geothermal(Heating/Cooling Supply) residential Water Supply(single) R ft it • _ •
OIndustrial/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: :• • ft. ft i' •
- • ❑Monitoring •❑Recovery : 1 . •
Injection Well: R ft
•
• ❑Aquifer Recharge ." ❑Groundwater Rernediation 19.SAND/GRAVEL PACK Of applicable) •
FROM TO • MATERIAL a EMPLACEMENT METHOD
❑Aquifer Storage.and Recovery . .❑Salinity Barrier . ft . . ft , m; . .
•
❑Aquifer Test • O Stomrwater Drainage • •
ft. ft
['Experimental Technology ❑Subsidence Control p •
20.DRILLING LOG(attach additiaaal sheers ifnecessaey) •
❑Geothemial(Closed Loop) • ❑Trtuer : •PROM TO DFSt:RIPTION color,hardness,soWrocit type,grain size,etc.)
❑Geothermal(Heating/Cooling-Return) • ❑Other(explain under#21 Remarks) (2 ft Q/S .ft • ih iy
4.Date Well(s)Completed: •• _ Well ID# • •QQq•ft. /t " •ft- /i!q(1�s���""
• Sa Well /./l�"ft a ft L't, /HOC/<'
_ ( fS' ft- 3t7s ft wISC
i}i t h Cranip"6J.r t., Liz • . . f` ft:
Facility/OwaerName ' ": FacilitylD#(if applicable) - . . . ft •
i, ^ ; .R" �• ._-I; . a ,i
G /c6I,4�',P'!GC 'A$u'ike avg7 , 7 fit ft p
Physical Address,City.add Zip . 21.REMARKSL
on "S[+ 2 7 20 23
ly Parcel Identification No.(PIN) �;C.*p, •
. Sb.Ladtude and Longitude in degrees/minutes/seconds or decimal degrees:. 1
•
(if well field,one lat/long is sufficient) 22 Certification: i;
-S° - / , ?, 7c, N 8a°3.S`e'S r3i,c '' w ' c • ‘,(/i .
S o edll Contractor I, • L to
6.Is(are)the well(s): l rmaneat or ❑Temporary . By signing this form,I hereby certify that the wells)was(were)constructed in accordance •
• with ISA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Condructon Staudards and that a
7.Is this a repair to an existing weft: .• ❑Yes or ' 6No copy of this record has been proidekd to the well owner.
If this is a repair,,fill out brown well consbarcliori n onnalion and explain the nature of the i
repair wider#21 remarks section or on the back of thisfonn. • 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 nwlllple infection or non-water supply wells ONLY with the saran construction;you can
submit one fonn SUBMTTIAL INSTUCTIONS .
9.Total well depth below land surface: • 3i5 . - (ft,) 24a. For All Wells: Submit this form within"30 days of completion of well .
Formrdtiple wells list all depthsifdffere nt(example-3Q200'and 2Q100'). ' construction to the following:. - .
10.Static water level below.top•of casing; ern • • . (ft) Division of Water Quality,Information Processing Unit;
Ifwater level is abase casing,,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter' "` 4) " (in.) • 24b.For biiertion Wells: In addition to sending the form to the address in 24a
•Rota above, also submit a copy of this fomi 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 Injectimi Control Program,
.FOR WATER SUPPLY WELLS ONLY: . 1636 Mail Service CetWer,
4 Raleigh,NC 27699-1636
13a.Yield(gpm) A() " Method of test: Blowing-Rig 24c.For Water Supply&Iniection Wells: In addition to sending the fora to .
the address(es)above, also submit one I copy of this form'within 30 days of
• Chlorine (fig . oZ• completion of well construction to the county health department of the county
13b.Disinfection type: Amount:
where constructed
1
Form OW-1 • North Carolina Department of Environment and Natural Resources—Division of Water Quality, Revised Jan.2013 •