GW1--06462_Well Construction - GW1_20231002

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W 111.LL L uii►01ItLi L. Hui' KLL+I:UK11 For Internal Use ONLY:
.This form can be used for single or multiple wells
1.Well Contractor Information:
BobbyW Potts 14.WATER ZONES I. i
. . FROM . TO DESCRIPTION
Well Contractor Name ft 370 R ,
•
NCWC 2028-A ft 600 ft •
NC Well,Contractor Certification Number 1S.OUTERCASING(for mulfidsed wills)OR LINER(if a ble)
. FROM To DIAMETER. THICKNESS MATERIAL
Ferguson's Well and Pump, LLC 0 f4 C �ei, " 42!Sin 2/6t/ ' P'cs'.p, v
• Company Name • 16.INNER G OR G.(geothermal dosed-loop)
FROM TO • DIAMETER THICKNESS . ' MATERIAL
. • 2.Well Construction Permit#: S(j ,. a - 1. be�a( ft. ft. • ; in.
List all applicable well construction permits(i.e.County,State,Variance etc.)
ft ft in
3.Well Use(check well use): .17.SCREEN
• Water Supply Well: FROM TO DIAMETERS SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Munic' blic ft ft is• .
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft in.
❑Industrial/Commeroial OResidential Water Supply(shared) la
FRO GROUT M TO MATERIAL ' EmPLAcEmENf METHOD a AMOUNT
❑Iaigaation 0 ft 20 ft Concrete Gravity-Flow
Non-Water Supply Well:. ft ft
❑Monitoring ❑Recovery '
Injection Well: ft ft •
i
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK Of applicable)
FROM 'TO MATERIAL EMPLACENIFN'rMETHOD
❑Aquifer Storage and Recovery ❑Salinity-Barrier ft 1
❑Aquifer Test ❑Stormwater Drainage
ft ft 1.
❑Experimental Technology ❑Subsidence Control r t
20.DRILLING LOG(attach additi�al sheets ifnecasssary)
❑Geothermal(Closed Loup) ❑Tracer FROM TO DESCRIPTION/color,RIPTION(calor,hardness,sollroclt type,fawn etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) '' (/
�,,�� ft. SS ft.. G �157foicc.
4.Date Well(s)Completed: � atU//1 S Well ID# FS ft.
MO
ft .5'as Weil Location. J (0 )rt ?( tlftel c/C
VtIn• e. /2Aara.9 e� /i�. ft 7�zs f` (',-�irr�f'] c
Y ft ft
Facility/Owner Name _ Facility lD#(if applicable) K • y P r
67 r r) Z1r?7 )r it cc- Aldo() .2 Er 7&f ft. ft ;. �!�
Physical Address,City.and Zip 2L REMARKS O C IT tf 2, 2023 •
/ el)aih// »a1 boa44 aag9
hr;..,„ ..�_0 ;': _•. ,• a:.i U.
County Parcel Identification No.(PIN) ! G; ,�,i.,Zi
Sb.Latitude.and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification: ;
31 YS�32„306• " N / •°57135..2 82 '" W •
• j0
Si • of ed for by
6.Is(are)the well( /44;3_
s): C7Permanent or ❑Temporary
B3'signing this fora;thereby certify that,the weA(s)was(were)constructed in accordance
with 1SANCAC 02C.0100 or 1SANCAC 02C.0200 Well Construction Standards oral that a
7.Isthis.a repair to an existing well: • ❑Yes or laivo copy of this record has been provkkdtothe well owner.
•(/'this is a repair,fill out brown well construction bfonnation and eaplabr the nature of the
repair carder#21 remits section or on the back 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 h&c supply wells ONLY with the sane construdion,you can
submit anefonn SUBMITTAL INSTUCTIONS i,
9.Total well depth below land surface: (J° 5 (ft,) 24a. For All Wells:. Submit this form within 30 days of completion of well
mu
ltiple ultiple wells list all depths ifthfferenl(example-.3(a 00'and2(4100') construction to the following:
10.Static water level below top of casing: 6(7 (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service I enter,Raleigh,NC 27699-1617
11.Borehole diameter. Y` (in.) 24b.Dior Injection Weiss: 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.)
Division of Water Quality,Underground Injectiot Control Program,
' FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service i ter,Raleigh,NC 27699-1636
13a.Yield(gpm) 3 Method of test Blowing-Rig 24c.For Water Snooty&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13k Disinfection type: Chlorine Amount: 6d, oz. completion of well construction to the county health department of the county
where constructed.
Form SW-1 • North Carolina Department of Environment and Natural Resources-Division of Water l Qu ity Revised Jan.2013 •
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