GW1--04136_Well Construction - GW1_20240717

W H:LL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells •
1.Well Contractor Information: —
ts 14.WATER-PANES_
Bobby W. Potts FROM TO ' r DESCRIPTION
Well Contracts Name ft. /%'d ft .
NCWC 2028-A ft ft — •
NC Well Contractor Certification Number 15'OUTER CASING(far mulHmed wells)Ok UN=Of aikdinble)
. PROM TO D1AM ETER TRICENIESS PLATIRIAL
Ferguson's Well and Pump, LLC C) s y r2 bi. 2jb/1.: fcsp 72/
Company Name 2 r 16.INNER CASING OR r:+ G(geidseemsI daedaoop)
r�lJ. ?s`�' PROM ,_TO DIAMETER THICKNESS MATERIAL
2.Well Construedon Permit#: ft ft in.
List all applicable well construction permits(i.e.Corouy,State,'Variance,etc.) ft ft.— is
3.Well Use(check well use): 17.SCREEN _
Water Supply Well: FROM TO DIAMETER I SLOT SITE THICKNESS MATERIAL -
❑Agtictulltrral 01.4,ra 1/Public ft it n i—
—
.
❑Geothermal(Heating/Cooling Supply) Cuesidmtial Water Supply(cingir) ft ft in. I
❑IndustrialCommeruiai ❑Residential Water Supply(shared) 18.GROVE � -
DItrigBtion FROM TO MATERIAL EMPLtCI1l�lTMEIHOD&AMooter
- p
Non-Water Supply Well: ft 20 Concrete Gravity-Flow
❑Monitoring ❑Recovery ft. — ft —_
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(If artsifeaHg
FROM TO MATERIAL EMPLACEMENT METHOD —
DAquifer Storage and Recovery ❑Salinity Bathe ft -
❑Aquifer Test ❑Stemiwater Drainage
ft. ft.
❑Experimental Technology 0 Subsidence Control t
20.DRILLING LOGfattaeh additional shale ifaeoaaaat
❑Geutbermal(ClusedLoop) ❑Tracr FROM TO DESORPTION� /e.ar.harsdurodweannr ere)
❑Geothermal(Heating/CoolingJReuan) ❑(,titer(explain under#21 Remarks) O n 20 t -ft
4.Data Well(s)Completed: `// 2,2 well Mir 20 3 it ��
35 ft- `, O ft -c' e 0 es/c
3a Well Location: •
/a ft. d� ft.
• `fd`lac J,i/. -
Facility/Owner Facility ID#(if applicable) rr . a
V t(-'W I� M A C1t t)L) (�(�.Lea � 7(1 I Ct ft ,,
Physical Address,City,and Zip ^� 21.REMARKSill I f
rV'fYrl b e Sit ll 3aNa a.i.r..,..,4
County Parcel Identification No.(PIN) U/to.r"".
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one latAong is sufficient)
22 CertiSeation:
? `/ ' SSA N `' sf : �� w ` .
,, �s1;, 1 ,�' _ 4
signature of Ceslift d Well Con to
6.Is(are)the well(s): C}Farmanent or ❑Temporary By,ice this forre,1 yereby,certifr that the well(s)was(were)constructed in aoconlancc
�' with ISA NCAC 02C.0100 or 1.5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an'misting well: ❑Yes or Ell copy of this record has been provided to the well owner
tf this is a repair,fill oast brown well construction irfarrmation and explain the nature of the
repair corder#21 remarks section or on the back r'tldsfomL 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 rir•tails. You may also attach additional pages if necessary.
For multiple infection or non-water supply wells ONLY with the sane construction,your can
submit one fi,w SUBMITTAL INSTUCTIONS
9.Total well depth below land s ide=r 0S (B,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths Oifferem(euanple-3 00'and 2 c)100') construction to the following:
10.Static water level below top of casing: ..51 1 (ft•) Division of Water Quality,information Processing Unit,
.jfwater level is above casing,use"+" 1617 Mail Service Canter,Raleigh,NC 27699-1617
11.Borehole diameter. i l/Q cm.) 24b.For Infection 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,sleet push,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Canter,Raleigh,NC 27699-1636
13a.Yield(gpm) / Method of teat: Blowing-Rig 24c.i'or Water Sneul,E baiection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
131> Chlorine Amount: 4 (,� 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