GW1--06342_Well Construction - GW1_20230927

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information:
Bobb W. Potts 14.WATER-ZONES:: --.. .. i,.
Y FROM TO ' , DESCRIPTION
Well Contractor Name ft .„....ft`
NCWC 2028-A ft ft I
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NC Well Contractor Certification Number 1S.OUTER.CASING(for multtcased wells)OR LINER(if all cable)
. FROM TO DIAMETER, THICKNESS MATERIAL
Ferguson's Well and Pump, LLC 0 ft A 4 ft 6,1•.;5'in• Z/61./as eCSP1 Z-(
Company Name . 16.INNER CASING ORTUBING:(gza1 closed-loop)
2.Well Construction Permit#: ()odd -- O 6 3 5 a FROM TO DIAMETER THICKNESS MATERIAL
ft ft 1 in
List all applicable well construction permits(1.'e.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 ❑Muuicipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in
❑Industtial/Commercial, ❑Residential Water Supply(shared) '18.GROUT . -
FROM TO MATERIAL PLACF2ti N'f 11MET'HOD&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 81applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
EM
❑Aquifer Storage and Recovery 0 Salinity Barrier ft. 9
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❑Aquifer Test ❑Stormwater Drainage
ft ft • I
❑Experimental Technology ❑Subsidence Control r
20.DRILLING LOG.(attach additional sheets if necessary)
❑Geothermal(Closed Loup) ❑Tracer FROM TO DESCRIPIYU (color,hardness,soNrock type,grain sire,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. /5 .ft C (a
4.Date Well(s)Completed:gf�7/?iO2�Well UM r 5, ft 20 ft. (3q P1t 3/c. P
Sa Well Location: I Y��(, ft 2/ ft l q _/f(9 r /(CJ
+7� A.6 ft 70s ft ( ..�`,, e
Ems«______ 1-L-,viou ft. ft
Faculty/Owner Name Facility ITN(if applicable)
errar) OL n/ LL?-rt,� ti)e ilu:erLillt_ 2%7 t 7 ft. ft " . `+
Physical Address,City,and Zip 21.REMARKS . - SF P ro, 7 2 0/3
r3unepint a 6I-74!R'Qi S 555
County • Parcel IdentiScatioa No._(PIN)
DWOI OG
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certificatio :
(dwell field,one lat/long is sufficient)
3S a '6�Wr3/Cii slat r 14 13 7, �108'7 l w A/`, ! 7/2623
Signature of Well Contractor Da
6.Is(are)the well(s): g rmanent or ❑Temporary By signing this form,I herebycertifrthat the well(s)was(were)constructed in accordance
with 1SA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or al o copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
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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 same construction,you can I
submit one form SUBMITTAL INSTUCTIONS '
9.Total well depth below land surface: ---7 .S (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@200'and 2@100') construction to the following: I
10.Static water level below top of casing: a (ft) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" . 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: :Y-._ 12 (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Rota above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ry construction to the following:
(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 27699-1636
13a.Yield(gpm) 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 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 OW-1- North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013 •
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