GW1--06343_Well Construction - GW1_20230927

WLt•LL CUNS7l'KUCIION RECORD For! eal Use ONLY
This form can be used for single or multiple wells
• 1.Well'Contractor"Information: : • •
• . •
Bobby.W. Potts" - 14.WATERZ
ONES t I "
•
• FROM TO . .DESCRIITION -
• Well Contractor Name fc: • ft
• NCWC 2028-A ft r1
.. NC Well Contractor Certification Number 15.OuTTER CASING(formuld.casedheells)ORLNER(rapg/cable) .
FROM TO DIAMETER I THICKNESS MATERIAL
Ferguson's Well and Pump,.LLC v it �rr1�i '" �t<", . jOiCSD �/
.Company Name . . . ' . . 16.INNER G OR TUBING.(aeethetmsl dosed4oup—) • " -
. . " ' - FROM " TO DIAMETER . THICKNESS .' MATERIAL
2.Well ConstruedonPermit#e. :'CRQe21 " GGyCrY .ft. ft •- I in.
List all applicable well constni¢don permits(ie.Comity,Stale,Vanmtce,eta) ft.- • .ft I hi. ,
. 3.Well Use(check well use): 17.SCREEN
'Water Supply Well: ' : ' : 'PROM TO' DIAMETER: SLOT SIZE THICKNESS MATERIAL _ :
. .ft ft. •in. •
❑Agricultural. . ❑ pal/Public
❑Geothermal(Heating/Ccoling Supply) . tial Water Supply(single) . ,- . ft ft, in.;
' - ❑lndustrial/Commercial OResidential Water Supply(shared)' 18.GROUP . . . -
❑IiriQation " •
FROM To_ MATERIAL- • EMPLACEMKNTMETIiOD&AMOUNT '
Non Water,Supply Well:• ' . 0 it 20 ft Concrete" Gravity-Flow "
ft' ft .
❑Monitoring - . IRecovery •
• Injection Welk - -ft. 'ft. ' :
DAquifer Recharge . . . - . . ❑Groundwater Remediation " . ' . 19.SAND/GRAVEL PACK Of medicable) . . . . . .
❑A Storageand FROM • TO MATERIAL, - EMPLACEMENT METHOD _
quiferety . .❑Salinity Barrier . ft. ,f. •. -,
' • DAquifer Test • ❑Storarwater Drainage Et
❑Experimental Technology. ❑Subsidence Control -• p
2QDRILLING LOG(attschadditioaalsbeetsifneeessar9) " '
• ❑Ge euth nasal(Closed Luup) • . ❑Tracer ' ' • • . " ' FROM . • TO . DESCRIPTION(color,hardness,soli/rock type,grain she,eta)
❑Geothermal(Heating/Cooling Return) - OOther(explain under 21 Remarks). U! ft 70 .ft 11'1,e Y .
4.Date Well(s)Completed: //j •WeII"ID# • ©' f �s it 1 l�L! . C tC ;
f'S ft. /OA rt ,4-r /'oc/c "
Sa-Well Location: •
�y Y _ 1
�nhn ' LP b //9`f 1OS'"EtG(JiT�. .
FacilitylOtvner Nano `J C Facility 1171!(if applicable) I '`� .
ft ft II r 66 C--k' L- •i -1
. �� 4-i'L...r 1/4,, „l a)
�4l/'bh wifi : rflrvve .-a/,vl'tty o1- 73C. ft it . . i SEP 2,, 7 2Q2�
Physical Address,City,end Zip . 21.REMARKS: • " 6
tarn�,,,(,j,� 661�7(aaaa eaoa • In ,r1tt4..,it ,-.r:-`:,rt�,'.a.3 i! ,' "
• County Parcel Identificafion No.(PIN) I GA::`ti c;�`:pia
•Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: " :22 Certification:
: (if well field,one lat/long is sufficient)"
35°y5 06 t. .10e%/• jr•N .• y�.°,2%a),?/ ' 0 W .• / ). -2' 1/ -
•
. �. Signature of C�ed Well Contractor ; to
6.Is(are)the well(s): ,Permanent or OTemporary
. By signing this four;I hereby certify that•Ilia weA(s)was(were)"constructed in accoxlrmce
: With•ISANCAC 02C.0100 or ISA NCAC 02C:0200 Well Construction Standards and that a
' " 7.Is this a repay to an existing well: ❑Yes, or HNo -•" " ., copy oftlris recordhas been provided to the ivell owner.
gilds is a repair,fill out known Well construction information and explain the native of the ' 1,• repair:order#21 remarks section or on the'back of thlsfonn. • • . - 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 beection or non-watersypply wells ONLI'with the same cons ruclibn,you can • •
submit onefonn " ' SUBI4IITTALINSTUCITONS - j
9.Total well depth below land surface:• " W c .(ft.). 24a. For All Wells: Submit this form within 30 days.of'completion of well
Form uldple well list all depths ifdifirerent(example-3@200'and 2@100) • construction to the following: "
. . • 10.Static water level below top casing:. " - `jf� . " . (ft)' Division of Water Quality,of Information Processing-Unit;
If water level is above casing,use"+" 1617 Matz Service Center,Raleigh,NC 27699-1617 .
11.Borehole diameter: .: (in) •
•24b.For Infection WeDs:_ In additionI,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 prisb,etc.) -
Division of.Water Quality,Underground Injection Control Program, .
FOR WATER SUPPLY WELLS ONLY:. .1636 Mail Service Center,Raleigh,NC 27699-1636
I -I
13a.Yield(gpm) $ Method of test Blowing-Rig 24e.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
nP • Chlorine �-; oz• completion of well'construction to they ccunty health department of the county
136.Disinfection e• Amount: •• • " - • • • • where constructed.
Form OW-I •. North Carolina Department of Environment and Natural Resources-Division of Water Quality , Revised Jan.2013 • .
I •