GW1--06336_Well Construction - GW1_20230927

W MA.,LAJI l b 1 KIJ 1:11U1V .K.MUKIJ For Internal Use ONLY:•
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobby W. Potts •FROM
TO NES_• • .lb.1tSCRILriION
•Well Contractor Name ft. ft I
NCWC 2028-A ft Sro ft I
NC Well Contractor Certifi cation Number • • '15.OiJTERCASINGifor ifr aced.yiells)ORLLNER(dapnleable)
FROM TO .. - DIAMETER k/41A5
ICSNFSS MATERIAL
Ferguson's Well and Pump, LLC • . dft ��sa3 ft (Or. 11L pj421
Company Name 16.INNER GORTUBING.(rita>hermalelmed )
' PROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: . 2 02 3— .660.75— ft • ft ;a
List all applicable well consstructon permits(se.County,State,Variance,etc)..
tt ft i; in. .
3.Well Use(check well use): 17 SCREEN ! _
Water Supply Wen: FROM TO DIAMETER SLOT SEE THICKNESS MATERIAL
❑Agricultural • ❑ lie ft ft in'
❑Geothermal(Heating/Cooling Supply) :side/dial Water Supply(single) ft. ft
Olndusttial/Commercial ❑Residential Water Supply(shared) :18-(Ri°CT.. • _
FROM TO MATERIAL . F111lPI.ACEMI!Tl'f METHOD t}AMOUNT
❑Irrigation 0 ft 20 ft Concrete Gravity-Flow
Non-Water Supply Well: . ft. ft A
❑Monitoring ❑Recovery -
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation, 19.SAND/C,RANEL PACK. f. ie)
PROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
0-Aquifer Test ❑Stomrwater Drainage ft ft 1'
❑Experimental Technology ❑Subsidence Control
:.28:DRRL =7A (ittacli`d deal shares ifnecsaars)
❑Geothemtal(Closed Loop) OTracer PROM TO DESCRIPTION(color,hardness,sollrodt type,grab she,etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 75 'ft I e fa �/
171
• 4.Date Weil(s)Completed: AO a� Well DM7S ft MO ft • (7,1 lbC
044 " l OC/C
41.21 as.Well Location. 1`l S • �[G
fft. / ft 6114i 0 V/`
rice " //A/W/Us1 ft. �D ft
Facility/0;voer Name r- Facility ID#(if applicable)
38((y,,,,-KAr Way Fjeirj,�r a B1 - .. ft ft t,;...� I ,,r ,
Physical Address,City,and Zip ' '
2L REMARKS" S E P ° 7 2023
76tcricom(q_ . .
c!G,'li�le37
County Parcel Identification No.(PIN) I Ir:iJ rE'•.^._'..^,fl Pr^:' .;.ri:'.•j lsr t
5b.Latitude and Longitude in d ':}�" ``'z ngl ege afa®nntes/seconds or decimal degrees: 22.Certification:
, exec--
(dwell field,one lace long is2sufficient)
4v__,_,_
Signat
ure of ed Well Contractor is Da
6.Is(are)the wells): ertnaneat or OTemporary
BY signing this form I hereby Ce+'t+f1'thatitlie weTl(srwas(were)constructed in accordance
with 15A NCAC 02C.0100 or 1SANCAC 02C.0200Well Construc&nStandards and that a
7.Is this a repair to an existing will: OYes or QNo copy of this record has been Novick.uito the well owner.
rats is a repair,fill out brown well construction information anderplabt the nature of the ;'
repair under#21 rmrmia section or on the back of this foam 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.
Fornaduple h&c fiat or non-water supply wells ONLY with the same construction,you can 1, '
submit oneform n r SUBMITTAL INSTUCTIONS I '
9.Total well depth below land surface: 'kV-5 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells lit all depths ifdrffemht(example-3@200'and2@100) - construction to the following: •
10.Static water level below top of casing: (ft.) Division of Water Qualitj,Information Processing Unit,
(f water level'ts aboi2 easing,use"+" 1617 Mail Service Center',Raleigh,NC 27699-1617
11.Borehole diameter. :T (in). 24b.For Injection Wells: In addition to ending the form to the address in 24a
Rotary above, also submit a copy of this fom within 30 days of completion of well
12.Wel.constructionmethod: construction to the following: i i
(i.e.auger,rotary,cable,direct push,etc.)
• Division of Water Quality,Underground Injectiog Control Prpgram,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center;Raleigh,NC 27699-1636
11
132.Yield(Sp nr) Y Method of test.. Blowing-Rig g Blowin Ri 24c-For Water Sunnily&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: A ' oz. completion of well construction to the county health department of the county
where constructed I I'
Form OW-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality' Revised Jan.2013