GW1--04141_Well Construction - GW1_20240717

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contactor Information:
Bobby W. Potts 14.WATER EONEsa
PROM TO r DFSCRIPITON
Well Contractor Name ft. R/0 ft
NCWC 2028-A ft ft
NC Well Contractor Certification Number 15.OUTER.CASING(for mnificeaed arms)OR LINER Cif hale)
FROM TO DIAMETER Tom` MATERIAL
Ferguson's Well and Pump, LLC ; tl -1.;0 n 4,A 'i21. 2-16/f. AtcSPe2%,,
•
Company Name 16. CASING OR TURNG(apitheirmal closed-load_
r 7 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: k/r lI -. Q .--� 4)O t4 ' - ft ft in
List all applicable well construction permits tree.County,Stale,7'arrarce,etc.) is
ft ft
3.Wear Use(check well trse): 17.SCREEN
Water Supply Weil: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
DAgricultu al ❑ • lic ft ft to
❑Geothermal(Heating/Cooling Supply) dential Water Supply(single) ft ft' m.
❑Industrial/Commeaeial ❑Residential Water Supply(shared) 1S.(iROO T —�
FROM TO MATERIAL IMPL,tCI TMEIHOn&AMOUNT
N❑n-Wa aterSupply Well
� 0 ft 20 Concrets Gravity-Flow
ft ft
❑Monitoring DRecovery _ --
Injection Well: ft ft
❑Aquifer Recharge ❑Grooidwate Remediadou 19.SAND/GRAV&L PACE.fd avolicsdieji
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL-0 EMPLACEMENT Mxrnon
f. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsideaoc Control —r
20.DRILLING LOG.(zitn&additional sheets lfas eo.o9)
❑Geuthemaal(Closed Luup) ❑Tracer FROM TO DES Tr(color,hardness,+oi ape,crate mc,•mi)
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) (f ft y0 eft 0
4.Date Well(s)Completed: V/ A V/-/ Well 1D# t/0 ft SS ft S k
/ 5•; ft 1'0 ft P
Si.Well Location: if) ft '
--V
t.
`r"',11�'j l v."4�t'
11 t le MD ks_ GDP /4/6 ire ft. .
Faciiity&O nerName Facility Mir(if applicable)
ft. ft ..%..., v 1
7 iliz' LIJ E - P64, Lt iP" 2 7(itQ ft ft ILL 1 f 7(124
Plkvsical Address,City,and / p 21.REMARKS
n be 8/0 ! 1®-44,rd:3/)J[be) irio•..4 Tn A,-.n tt:r...
County Parcel Identification No.(PIN) MC,/$Gi''
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lal/long is sufficient) >
35"35 r3.988 N <<, 3 3 . 'W — )�1� �% Lei,_. 2-.%
.,/ ‘./ /2..y-
/ Signature of C cd Wall Cos actor
6.Is(are)the weD(s): C ermanent or OTemporary By,signing this form,I hereby=VP that the well(s)was(were)constructed to accordance
/ with 15A NCAC 02C.0100 or 15A NCAC 62C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or O copy of this record has been provided to the well owner.
ithis is a repadr,fill ma brown well construction information and explain the nature of the
repair wider#21 remarks section or on the back of thLsfonn. 23.Site diagram or additional well details:
p You may use the back of this page to provide additional well site details or well
8 Number of wells constructed: Iconstruction details. You may also attach additional pages if ate'.
For multiple tq/ecuton or mar-water supply wells ONLY with the same construction,your can
submit are fa,,,, STBRIITTAL INSTUCTIONS
9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this farm within 30 days of completion of well
For multiple walls list all depths tf4 Pratt(example-3( 200'and 2g100') construction to the following:
10.Static water level below top of casing: ,2N 0 .. (ft) Division of Water Quality,Information Processing Unit,
If water level Is above casing,use"+" 1617 Mad Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: -` 4) (m.) 2411.For Injection We11a: In addition to sending the form to the address in 24a
ry above, also submit a copy of this form, within 30 days of completion of well
12.Well construction method: Rota construction to the following:
(i.e.auger,rotary,cable,direct push,eta)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Marl Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Blowing-Rig 24c For Water Sunnily y&Injection Wells: In addition to sending the formto
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the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chlorine Amount 30 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 Ian.2013