GW1--06332_Well Construction - GW1_20230927

WILL W11l►M1AUL,IIVA Kt UU1(v `U For Internal Use ONLY: i
This form can be used for single or multiple wells 1 k.k
1.Well Contactor Information:
1!'
BobbyW Potts 14.WAT ES ERZON . . , I
. . FROM TO. , DESCRIPTION
Well Contisetor Name ft /73 ft
NCWC 2028-A ft a z? ft . 1 1
NC Well Contractor Certification Number 15.OUTER CASING(for mnld.àscd wells)OR LINER(if spllcsl1c)
- FROM TO DIAMETER I THICKNESS MATERIAL
Ferguson's Well and Pump, LLC a 6('S f , 2 4 fPS 4Uc5 ()g2/
Company Name . 16. rt CASINGTU OR BING.(geothermal dmaddoop)
2.Well Construction Permit#: ai 6t�3 - 0665 9 ft FROM TO DIAMETER THICKNESS MATERIAL
List all ft ' me
applicable well construction pemdts(Le.County,State,Yariarxg etc.)
ft ft i h
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑ ipal/Public ft ft in
❑Geothermal(Heating/Cooling Supply) NAresidential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT -
❑II17a8tiOn FROM ft. ft
TO MATERIAL EMPLACHIIFNT METHOD&AMOUNT
' Non-Water Supply-Well: 20 Concrete Gravity-Flow
❑Monitoring [Recovery ft
n
Injection Well: ft. ft.
❑Aquifer Recharge .' ❑Groundwater Remediation 19.SAND/GRAVEL PACK Of applicable)
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
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loup) • ❑Tracer FROM TO nrstat rroN(color,hardness,soil/rack type,scale st2e,etc)
❑Geothermal(Heating/CoolinF Return)� • ❑Other(explain under 821 Remarks) 0 ft 616 ' .ft /t t� � ..
4.Date Well(s)Completed:l// A.3 Well Mir CIO ft �/O ft `� ��i5 4.t'!/L
/r)h 1/5 ft / ("cot: /c
aa.Well Lunation: R ft f _ F
Tr�igtn &nip D.e.d LLC. // 3pS ft °�, e -
Fac
ility
_/Owner Name Facility ID#(if applicable) ft ft ,17-,7 a 'ICI-
1
( ? Wilson tf,'pd t ut ao4'I't`/l l if m9j/J7 ft. ft -4.;, . v h. ,.
Physical Address,City,and Zip
Rl:riconm b e •q 734 38c 8 Pea �' REMARKS S E P 3 ' 2C 23
County Parcel Identification No.(PIN) lnf 1,rratP' 1 N r; F. N.:.9 t;r:t
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal.degrees: --y J V
(if well field,one lat/long is sufficient) 22 Certification:
3s°VS f6', 707/ t' N 9 "3 S ° 'S O '5r W �y��,�1, l
�� Sig Lure ofC fled well coht actor IJate��F
6.Is(are)the well(s): f21 ermanent or ❑Temporary By signir g this form,I hereby certify that,the wells)was(were)Constructed 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 2'Plo copy of this record has been provided to the,well owner.
If this is a repair,fill out known well construction bjonnation and explabn the nature ofthe j
repair under#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 -
8.Number of wells constructed: / construction details. You may also attach additional pages if necessary.
For multiple byectiou or non-water supply wells ONLY with the sane construction,you can
submit one form SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: ,b (ft) 24a. For.All Wells:. Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@20Oand 2Q100) construction to the following: -
10.Static water level below top of casing: Ito (g,) Division of Water Quality',Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center;Raleigh,NC 27699-1617
//
11.Borehole diameter: ` ( ) (in) 24b.For Iniection Wells: In additioa to sending the form to the address in 24a
•
Rota above, also submit a copy of this fora 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 Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center;Raleigh,NC 27699-1636
13a.Yield(gpm) A 0 Method of test: Blowing-Rig 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit,one I copy of this form within 30 'days of •
136 Disinfection type: Chlorine Amount: y5' oz. completion of well construction to the county health department of the county
where constructed.
i
Form OW-1 - North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013