GW1--04146_Well Construction - GW1_20240717

WELL CONSTRUCTION RECORD For Internal Usc ONLY:
This form can be used for single or multiple veils
1.Well Contractor Information:
BobbyW. Potts 14.WATER-ZONES_
. FROM TO • , DESCRIPTION
Well Contractor Name H• 10 ft .
NCWC 2028-A ft 3((0) ft
NC Well Contractor Certification Number 15.OUTER.CASING(formnl&eamed wells)OR LINER(if amicable)
FROM TO DIAMETER THICKNESS MATERIAL
Ferguson's Well and Pump, LLC 0 ft 7 f` /p., `;in' Zit',/ Pe(cD,22/
Company Name 16.INNER CASING OR G(Leta eenud daseddoop)
. FROM TO DIAMETER THICKNESS MATERIAL
I
2.Well Construction Permit#: Da - 6 6 y LI 1 ft ft in. —_
List all applicable well construction permits(ie.County,Stale,Varamace,etc.)
ft ft hat.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM To DIAMETER Fi2OT SIZE TmCIC EES MATERIAL
❑Agricultural ❑ ctpal/Public ft ft is
❑Geothermal(Heating/Cooling Supply) 0Residential Water Supply(single) ft ft ht. r
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT _ -
FROM TO MATERIAL. F£I PLACEME T METHOD&AMOUNTElimination
0 it 20 Concrete Gravity-Flow
Non-Water Supply Well:
ft. ft
❑Monitoring :Recovery —
Injection Well: ft ft
0 Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACT (ifmalleable.)
DAquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL--). EMPLACEMENT METHOD
ft ft.
DAquifer Test ❑Stormwater Drainage
—
ft, ft
❑Experimental Technology ❑Subsideacc Control ' r 20.DRILLING LOG(attach additional abets tinmeseary)
❑Geothermal(Closed Luup) ❑Traces FROM To DESCRIPTION(color,hardness,suture&type,non+tie,atc)
❑Geothermal(Heating/Cooling Return) DOther(explain under#21 Remarks) //C) ft 6 0 It (t I
i C
4.Date Well(s)Completed: V.,‘•V Well IDtt t .,) ft. 712t` .c' y*�� 7 � _ ? ft. - / c��
era.Well Location: (
ray ft • ft
E�> (Q.,ra U,-'i'At
�jrachr I Su9g s �jj ft. ft
Facility'OwnerName Facility ID#(if applicable) ft ft
`Jr u.c (('s_[._66u/I Lc«e.4 i e b,-7'/g ft. ft a
Physical Address,City,lad Zip 21.REMARKS
75t e P,Cnm5..e q 40 6C/ 3C/3116 1 i 20County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certifies n .n`"
(if well field,one lat/long is sufficient) 01 Caa
5 °36 '53, Si; '.N <'At / `),7 C3/e2 w I ‘, /4. tSignature of eel Wel] n for 44,4j2-(1
6.Is(are)the wellh): Pl manent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or Et o 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 ncrtre of the
repair Coder#21 remarks 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
8.Number of wells constructed: / construction details. You may also attach additional pages if necessary.
For multiple hgection or non-water supply wells ONLY with the same construction,you cm
subunit oefon. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 365 (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3(4200'and 2®100') construction to the following:
10.Static water level below top of casing: 110 • (ft-) Division of Water Quality,Information Processing Unit,
1f water level is above casing,use"+" 1617 Mail Service Center,,Raleigh,NC 27699-1617
11.Borehole diameter. i CQ (in.) 24b.For Injection Wens: 1n arirt Lion to sending the form to the address in 24a
Rotary above, also submit a copy of this form 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 SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
13a Yield(gpm) I 5 Method of test: Blowing-Rig 24c.For Water Supply&Injection Wells: In addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
136 Disinfection type: Chlorine Amount e7i11 oz completion of well construction to the county health department of the county
(i where constructed.
Form OW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013