GW1--04143_Well Construction - GW1_20240717

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells I
1.Well Contractor Information: _
BobbyW. Potts 14.WATER-ZONES_FROM TO • , DESCRIPTION
Well Con tar Name ft /10 ft - .
NCWC 2028-A ft. 2,/0 ft
NC Well Contractor Certification Number 1S.OUTER.CASING(for multi-cased wells)OR LINER(dam/:able)
FROM TO DIAMETER TRICrrnNS MATERIAL
Ferguson's Well and Pump, LLC ES0 ft. (OA k (10 OLS in glib//.15 Pcrc 5p,22.J
Company Name 16.INNER CASING OR TUBING(menthes-stud dased400p)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: Al/t1S I -( 6 L'13 d ft' ft. m'
List all applicable well construction pernrfls(i.e.Cowry,State,Variance,etc.) -
-
ft ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑ lie ft ft is
❑Geothermal(Heating/Cooling Supply) R.(esidential Water Supply(single) ft ft in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL ' EMPLACEMENT METHOD&AMOUNT
❑Irrigatiem 0 ft 20 ft Concrete Gravity-Flow
Non-Water Supply Well: • ft ft _~
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK Of sand calde]
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL F1vvfPLACE[r�^ITMETHOD -
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach addition$sheets if necessary)
❑Geuthermal(Closed Loop) ❑Trackr FROM TO DFSC'RIETKON(color,hardness,soft roctt type,grain nu,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) D ft Jos ft c�%�_ ,
4.Date Well(s)Completed: y t well iD# S9 iz ft 4.-; ft �t cr�i�/vJdS
5a Well Location: �(/ ft r, ` R />-Gd,'c /e.
( t rifsL rizi. .3109A74�/.-7 ��'�f ftt (�aw1R>�c .
Facilitywner
yyN��ame Facility II (if applicable) ft ft r .- r s '
s 13r6icife Lt�4-c7, 1).141( `""� / ft ft ,< --.
t
Physical Address.City.and Zip „-x I 7 y
`-� 2L REMARKS
4 Gin Con, I l tiz =+ra ,9
County Parcel Identification No.(PIN) ``mow` .� ir.•
Doh+.a gt.i;
5b.Latitude and Longitude in degrees/minntes/seconds or decimal degrees:
(if well field,one 1at/long is sufficient) 4,,, 22.Certification: t
3 5` 3. (3.4S Y ti f ie -/2 /43, .,-t;A w _. / ,•f' -- 2
Signature o ' ed Well ntractor to
6.Is(are)the well(s): 2rmanent or ❑Temporary By signing this form,I hereby certify that die well(s)was(were)constructed in accordance
with 1SA NCAC 02C.0100 or 15ANCAC 02C.0200 Well Construction Standards and that a
7.D this a repair to an existing well: ❑Yes or 21 4 copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 rnnanks section or on the back of this form 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: 7 construction details. You may also att•,ch additional pages if necessary.
For multiple bg'ection or nose-water supply wells ONLY with the sm a construction,you can
submit one form SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: g 1 5 (R,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfdttferent(example-3©200'and 2(t,100') construction to the following:
10.Static water level below top of casing: ,A 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. ` ` 62 (in.) 24k For Infection Well*: In addition to sending the form to the address in 24a
Rotary above, also submit a copy of this farm within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLYr�WFT.T,S ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) l() Method of test: Blowing-Rig 24e.For Water Snmily&Injection Wells: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chlorine Amount: :3 ,?\ 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 •