GW1--04154_Well Construction - GW1_20240717

WELL CONSTRUCTION RECORD
For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
BobbyW. Potts 14.WATER-ZONES_
FROM TO . , DESCRIPTION
Well Contractor Name ft 32--0 ft
NCWC 2028-A ft 5 ft
NC Well Contractor Certification Number 15.OUTER.CASING(for multi-cased wells)OR LINER(d'applicable)
FROM TO DIAMETIM THICKNESS MATERIAL
Ferguson's Well and Pump, LLC 11 it c5f>ti /13_s in- 2.jay( °i4c5 1),2Zi�
Company Name 16.INNER CASING OR G(geothermal dosed-Ioop)__
FROM TO DIAMETI1t THICKNESS MATERIAL
2.Well Construction Permit#: lJ a LI- out? i ft ft. m. -
List all applicable well constrstcdonpermits(t.e.County,State,Variance,etc.)
-
ft ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: PROM TO DIAMETER _SLOT SIZE THICKNESS MATERIAL
ft ft ' in
OAgricultural ❑ lie _
OGeothu ft ft in.mal(Heating/Cooling Supply) csidential Water Supply(single) -
❑IndustriaUCommercial OResidential Water Supply(shared) 18.GROUT _� -
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Inigatioa
Non-Water Supply Well: ft 20 Concrete _-Gravity-Flow
❑Monitoring ❑Recovery ft ft --
i
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remcdiatiou 19.SAND/GRAVEL PACK 6f applialdc)
FROM TO MATERIAL_ EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. tt .. • '
❑Aquifer Test OStoaawater Drainageft. R -
OExperimental Technology ❑Subsidence Control . r
20.DRILLING LOG.(Math adtlllional Age&if teary)
OGeuthetmal(Closed Loop) ❑Tracer PROM To DESCRIPTION(color,hardness,soil/rock bpe,grain she,etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft ZQ eft (''/ft,t/
ft 4.Date Well(s)Completed: 0/2.7 Well ID# 70 ft
pa _Lc?�J � /'C�
ry ft 17 ft. -_• /I((C.
5a.Well Location: iJJ ,E
Kr.Vj`in NI ICC" ft 3-6 rt.
,
Facility/Owner Name r' ` Facility ID#(if applicable) R ft
0b It,)f-s C,til� L4 iiu mac► L e t(' e 4f, r , z4 g - j` Y
�y_ ft tt +
Physical Address sad lip 2L REMARKS - I`[i I :1 2144
Lknrem11212 G-1baou a5-74
County Parcel Identification No.(PDT) 4.;'`1 .''r- ,y,'. '.1,w.t
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:`; 9//S �S3� �
: '7�"Y/� N G�I� i .r0q it W ' ;(•%''‘,/€ G/
(// grAZI2.1r_
Signature of C Sid Well Contras !r
r
6.Is(are)the weli(a): QPermanent or ❑Temporary
By signing this form 1 hereby certify that.ire weJl(s)was(were)constructed in 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 271Vo copy of this record has been provided to the well owner.
If this is a repair,fill out!Drown well construction b formation and explain the nature of the
repair rudder#21 remarks section or on the back of thisform 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 wets constructed: construction details. You may also attach additional pages if nrc.sary.
For multiple trtfection or nor-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCFIONS
9.Total well depth below land surface: S -s (ft) 24a. For AB Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths fdf erera(example-3@200'and 2( 100') construction to the following:
10.Static water level below top of casing: tb 11) ; (ft) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Matz Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 1 6 (in.) 24b.For Injection Wen: In addition to sending the form to the address in 24a
Rota above, also submit a copy of this farm 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 Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Marl Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) (0 Method of test Blowing-Rig 24c.For Water Supply&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 S' 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