GW1--06333_Well Construction - GW1_20230927

-•\I\/1...•a am a,V A AVL\-LW{..VL 1 -
Internal Use ONLY:
This form can be used for single or multiple.wells . 'For I
] . .
• . 1.Well Contractor Information:
Bobby W. Potts' • • . 14.WATERZONES;. •
FROM TO .:, DESCRIPTION .
•
Well Contractor Name ft •j ((Oft I I.
NCWC 2028-A ft ft
NC Well Contractor Certification Number • L5:OUTERCASING(for mnitt esaltwells)ORLINER(ifappaable)
Ferguson's Well and Pump, LLC FROM f` TO DIAMETER THICKNESS • MATERIAL
•
'Company Name . • • .• : 16.INNER CASING OR TIN (ailidsnmal dosed-lotud ' '� �1
�/ //,, f .-FROM • TO DIAMETER, THICKNESS. MATERIAL
2.Well Conant:11on Permit#: a6a -•U Y 10�O• ' ft ft i, in. • 1 . .
List all applicable well consttitction pemdts(i.e:Cmoity,State,Variance,etc.).. • •
• ft• ft. • I im.
'3.Well Use(check Well tide): 17.SCREEN
Water Supply-Well: • • . . . . FROM .- TO . DIAMETER ! .SLOT SPLE THICKNESS ,.MATERIAL . .
ft . ft im
❑Agricultural,. • ❑ rpal/Public• -
OGeothetmal(Heating/Cooling Supply) '[fi'Residential Water Supply(single) ' - ft ft in.i ' . •
Olndustrial/Commercial' - 1❑Residential Water Supply(shared) is.GROirr • . Ii . _ . .
FROM • ' TO MATERIAL EMPLACEMENTMETHOD�AMOUNT
. ❑Irrigation • • ' • 0 .ft 20 ft Concrete Gravity-Flow
Non-Water Supply well:,
• ❑Monitoring' . . . ❑Recovery ft ft a i .
'Injection Well: ' ' . ft. . ft.
['Aquifer Recharge. . • •DGroundwaterRemediation • 19.SAND/GRAVEL PACKS!" e) • .
❑Aquifer Storage.and Recovery ❑Salinity Barrier •FROM . TO MATEPI L , EMPLACEMENT
fi ft ';,
❑Aquifer Test . . • .DStomawater Drainage -
. ❑Experimental Technology ❑Subsidence Control ft �: ' ' P
20.DRILLING LOG(ittadiudiEthinal sheets ifneerssary)
°Geothermal(Clused Loup) . ❑Tracer . . .PROM TO • DESCRIPTION(color,hardness,soturocle type,seam she,etc)
❑Geothcmal(Heating/Cooling Return): ❑Other(explain under 421 Remarks) 0 ft l� •.ft' - .. I .(�s/a,` :
4.Date Well(s)Completed: 7/,. .,?3 Well BM
/S ft., S ft .D t*Pee'c.-.
rDa-We l Location:• • lA ' " 3S . • 6., ®CSC.
•
' Kevin M�•UClih .• , ft ft " ' I1
' .Facility/thew Name , Facility ID#(if applicable) . . . .
85.M gunk Aliy i2J AinOiall c9g753. • ft: • ft = .
Physical Address,City,sad Zip• .
�k omloc . . • C793 3a�(-I 3Fs21.REMARKS • ! • SEP 2 7 .2023. .
County •
. • •_ Parcel Identification No.(PIN)
•
Sb.Latitude and Longitude in degreehwnntes/seconds or decimal degrees: F ^ a ^.^ -irs- I!n j
(ifw well field,one laillong is sufficient) 22.Certification: I �:v�� .
•? '9 O alre.r N •S e q3•,3? �s c'rA w ,
. S• ofC�S' cd Well Contractor •
�� I.
6.Is(are)the well(s)::G+Pertnanent .or ,❑Temporary By signing this form I hereby ger*if'they're wel(stwas:(were)Coustrercted in accordance
with ISANCAC 02C.0100 or 1SANCAC 02C.0200 Well ConstnrcticnStarndards and that a
- 7.Is this a repair to an existing well: .• ❑Yes or - l2o - • . copy of thisrecord has been��is reprovi�d to the;well owner.'
pair,fell out brown well construction and eapleb;the nalzre of the !`
'repair wider#21 reaarks section or on the back ofthisform. 23.Site diagram or additional well details: '
You may use the back of this,page toi provide additional well site details or well
S.Number of wells constructed: . ‘ . : - :construction details. You may also attach additional pages if necessary.
For nudhlple ttgect1at or non-Water supply wells OMwith the sane coastrrid en,you can ' . ' i; . ,
submit oneform . SUBMITPAL INSTUCTIONS•. •
9.Total well depth below land surface: •- 7 OJ' (ft,) •24a. For All Wells: Submit this form within-30 days of completion-of well
For multiple wells list al dept s ifai ereni(example-3®200'and 2(tl00') construction to the following: . .
I.
10.Static water level below top of casing: .5d.• (ft.) • Division of Water Quality;Information Processing Unit,
ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
. 11.Borehole diameter :Tr..j . . 4 . On) 24b.For iniention Wells: In additi I�to sending the form to the address in 24a
Rta above, also submit a copy of this faith,within 30 days of completion of well .
O
12.Well construction method:. ry - . . construction to the following: t i .
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injectio6Control Pilpgram,
FOR WATER SUPPLY WELLS ONLY: - - ., 1636 Mail Service'Cent f,'Raleigh,NC 27699-1636
13a.Yield(Spin) -a• • Method of test: Blowing-Rig 24c.For Water Supply&Medical-Wells: In addition to sending the form to
- - :the address(es) above, also submit orie copy of this form,within 30 days of
' ' •13b.Disinfection type: Chlorine . . /,air. 9) Oz.• completion of well construction:to thi county health department of the county ,
where constructed. . . •
Form GW-1 • North Carolina Departmeat,of Environment and Natural Resources-Division of Water-Quality' Revised Jan.2013 ,