GW1--06384_Well Construction - GW1_20231002

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w LLuL 1.V l'id.a 1.KU L.1Min MECUM) For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bobb W. Potts . 14.WATER ZONES •
Y FROM TO . , DESCRIPTION
Well Contractor Name . ft. 3O?? ft I
NCWC 2028-A ft �;c ft E ,
NC WellConttactorCertificationNumber 1S•OlITER ING(ter m iti-cased wells)OR LINER(if applicable)
. FROM TO DIAMETER THICKNESS MATERIAL
Ferguson's Well and Pump, LLC O f4 90 a ('rALI'm Z/fir/,A5 o'ccp,ezi
Company Name . 16.1 NNER CASING OR TUBING( mat dined-loop)
/, FROM . TO ` • DIAMETER . THICKNESS MATERIAL
2.Well Construction Permit II:. (J 55 -p1 Orr) 3-0-7 5-6ft . ft ' li ;in
List all applicable well construction permits(ie.County,State,Vraim:ce etc.)
ft. ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural C 2 blic ft ft in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft in
Olndustrial/Commercial ❑Residential Water Supply(shared) • 18.GROUT I
FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 tti 20 ft Concrete . Gravity-Flow
Non-Water Supply Well: ft it
❑Monitoring ❑Recovery
Injection Well: ft. ft I, '
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK fdannlicsble) •
❑Aquifer Storage and Recovery El Salinity BarrierFROM TO MATERIAL EMPLACEMENT METHOD
f. ft
❑Aquifer Test ❑Stomiwater Drainage ft ft
❑Experimental Technology ❑Subsidence Control • ' • < p.
20.DRILLING LOG(attach additional sheets if masonry).
❑Geothermal(Closed Loup) ❑Tracer FROM TO - DESCRIPTION color,hardness,soll/rotk type,grain sue;etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) () ft ,6 v .ft ( (ay
4.Date.Well(s)Completed: Ø%'(2JWellID# u"U ft
7, ft.
t ! S`(((ir S Gv C -
Sa.Well Location:
Se'O f. ( a? t (VC/et);71 e
' ;t$6�s iicepthe/n S' ft. ft
Facility/OwnerName FacilitylD#(if applicable) r
ft ft .
36g5 tie, n L 4 ,ruct c.tU ig : 7--,P Tr' .s c.�.
>�7Re2 ft. ft �;,®;;�-,r L.l: s 'A...ism'
r
Physical Address,City,and Zip
lit n4 i-Jo f) es-3xV47.28q 2LREN17ARKS OCT 0 2023
•
unty Parcel IdentificationNo.(PIN) y� ,�7i;�;, Uflk
In'D;tic.''
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 Certification: L"P iJ r y,C;
Owen field,one lat/long is sufficient) f
3 Sir/ 1Qr- J ,N .$� '.33 '27iO3f c/row •-47, //, ./ ¢-- r
Signature of Certified-Well Contractor , D to
6.Is(are)the well(s):-C1Permanent or ❑Temporary By sivring flits form,Thereby cerli y ihat,the well(s)was(were)constructed in accordance
with 1SA NCAC 02C.0100 or 1SANCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: °Yes or Ble copy of this record has been provided to the well owner.
If this is a repair,fill out brown well construction information and esplain the name of the I
repair render#21 remarks section or on the bank 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 b#ection or non-water supply wells ONLY with the same construction,you can •
submit oneform SUBMITTAL INSTUCTION I.
S
Q I.
9.Total well depth below land surface: Y -5.. (ft.) •24a. For All Wells: Submit this fora within 30 days of completion of well
For multiple wells list all depths if different(example:-3e200'and 2@,I00') construction to the following:
10.Static water level below top of casing: i 0 (ft) Division of Water Quality;Information Processing Unit,
If water level is above casing,use"+" • 1617 Matz Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. ..-_ 4 Cm) 24b.For Iniection 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
II Well construction method: ry construction to the following:
• (i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injectioa Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) • 5 Method of test: Blowing-Rig 24c.For Water Supply&Iniecti I Wells: In addition to sending the form to
the address(es) above,also submit one copy of this form within 30 days of
136 Disinfection type: Chlorine Amount:- c 0 OZ. completion of well construction to the county health department of the county
where constructed. 1
I
Form SW-1 • North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013 •