GW1--04161_Well Construction - GW1_20240717

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used far angle or multiple wells •
1.Well Contractor Information:
Bobby W. Potts 14.
M'TERZONES T ' , =CMPITON
Weil ContractirName ft .•j l7/'ft •
NCWC 2028-A ft ft. _
NC Well Contactor Certification Number . 15.Ot1TER CASING(far mniftemsed sells)OR LINER¢f am&adie)
PROM TO DIAMETER THICKNESS MATERIAL
Ferguson's Well and Pump, LLC •
(,) ft V<)- (. r.X h. 2/6.r/)5 %G Y S p L?s
Company Name 16.INNER CASING OR TUBING(midterm'deed
DIAMETER- PROM TO E MATERIAL2.Wdn Construction Permit#: rQ�r�,� - 60 3?) ft ft to,
List all applicable well construction permits(i.e.County,State,Variance,etc.) —'—
ft ft no.
3.Well Use(check well rase): 17,SCREEN —Water Supply Well: FROM TO DUM ER sl.oT rues T IICICNas MATERIAL
❑Agricultural ❑Mtmio.pal/Public ft ft is
❑Geothermal(Heating/Cooling Supply) C3Residential Water Supply(singlr) ft ft i _
❑Indust ial/Commercial ❑Residential Water Supply(shared) 1S.GROUT -
FROM TO MATERIAL ' F�LACEMINTMETHOD&AMOUNT❑ �
Non-Water Supply Well: • O ft 20 ft- Concrete . Gravity-Flow
❑Monitoring ❑Recovery ft. ft —_ —
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND(GRAVEL PACK Of sooliabls)
FROM TO MATERIAL. EMPI EMQPIMETRoo❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft. -
—
❑Aquifer Test ❑Stotmwater Drainage • •
ft ft.
❑Experimental Technology ❑Subsidence Control -r
2.0.DRILLING LOG(steads additional Awl f )
❑Geotheamal(CIusxl Loup) ❑Tracer FROM To [ DF.StSUPTION Lagar,madae+s,+dUrock type,0uin milk are'
❑Geothermal(Heating/CoolingRettan) ❑Other(explain nnrirr#21 Remarks) L) ft 7.0 ft (I 1 ,
4.Date Well(s)Completed: `/`'/�V. Well ID# ZQ R ,y-; ft ‹��L�•Jl/ 6f r.
Sa.Well Location:
3/) ft yA ft el.COc�
1}c.h� 1 -- f r Y n S �• � cs�j7��
Facility/Owner Name Facility IN(if applicable) ft ft. `
34,a N h 14 l<1 b(ft) 4 i .si nil fl s c2P7? ft ft ��./ d L�t
Pf��Add ,and Zip 2L REMARKS
sneer the c1(oB88.3?1.5h6mn _
County Parcel Identification No.(PIN) MC
Sb.Latitude and Longitude in degrees/ndnutea/seconds or decimal degrees: 22 Certification:,
(if wall field,our let/long is sufficient)
3 S= ).5•� / /, �(�V . s.0,1�' -e.,, ).7 y'' W �U. �� � fe/_..,7 .. /r/� �i
� / Sigo�re of l Contractor bsic
6.Is(are)the well(s): CXermaneat or °Temporary By signisg this form,I hereby certifi,that the well(s)was(were)constructed to accordance
with ISA NCAC 02C.0100 or ISANCAC 112C.0200 Well Canstructka Stcordords cord that a
7.Is this a repair to an existing well: ❑Yea or 131Vo copy of this record has been provided to the well comer.
.jf this is a repair,fill out blown well construction bp'rmtaSon and explain the nature of the
repair under#21 rearmts section or on the back of thisfon 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
&Number of wells eansdrneded: construction details. You may also attach additional pages if necessary.
Fortebttmetlon o•nora•wahrsupply wells ONLY with the sane construction,you con INb�'UCITONS
f
9.Total well depth below land surfacer CS(?,cS (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For nnulttpk welts list all depths(f went(exanpie-3®200'and 41100) construction to the following:
10.Static water level below top of casing: `=(%% ' (fL) Division of Water Quality,information Processing Unit,
•fwater lave/is above casing,, "+" ur ,
1617 Mail Service Cter,Raleigh,NC 27699-1617
IL Borehole diameter: 0 , l// l l Q (m.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
Rotary above, also submit a copy of this fort within 30 days of completion of well
12.Well construction method: construction to the following.
(Le.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) .A Method of test Blowing-Rig 24c.For Water Sunni,&Infection Welk: In addition to sending the form to
the address(es) above, also submit one copy of this form within 30 days of
136 Disinfection type: Chlorine Amoral /,( 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 •