GW1--04175_Well Construction - GW1_20240717

WELL CONSTRUCTION RECORD For Internal Usc ONLY: - '
This form can be used for single or multiple wells
1.Well Contractor Information: -
14.WATER•ZON ES_
Bobby W. Potts FROM TO , , DESCRIPTION
Well Contractor Name ft. .f4490 ft _
•
NCWC 2028-A n s
NC Well Contractor Certification Number 15.OUTER.CASING(for multi-awed'Rdls)OR LINER Of applicable)
PROM TO DIAMETER TmCENTSS MATERIAL
Ferguson's Well and Pump, LLC ( ft* 77 ft. g X j& 2 j I/25 -, -05 y��L/
Company Name 1tS.INNER CASING OR G(geothermal dosed
-�ooQL
S r7a 'O FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: I ft ft in.
List all applicable well construction permits(i e.County,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 ❑Municipal Public ft ft in
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Rardential Water Supply(shared) 18.GROUT -
FROM TO MATERIAL ' E PLACEMKN T METHOD&AMOUNT
❑Irrigation -1Non-Water Supply Well: • 0 ft 20 ft Concrel:e Gravity-Flow
ft. ft
❑Monitoring ❑Recovery --
Injection Well: ft ft
0 Aquifer Recharge 0 Groundwater Remediatiou 19.SAND/GRAVEL PACK ftf applicable)
FROM TO MATERIAL EMP
LACEMENT PLACEMENT METHOD
0 Aquifer Storage and Recovery 0 Salinity Barrier -
ft ft:
❑Aquifer Test ❑Stomnwater Drainage -
-
ft ft
❑Experimratal Technology ❑Subsidence Control / r 20.DRILLING LOG(attachadildmsleets a if neemal9)
❑Geothermal(Closed Loup) 0 Tracer FROM To DZSCRIPTIoN color,hardness,sett/rock type,grata du,etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) IL . ) IL C�a y
/
4.Date Well(s)Completed://2 T It Well BM 6- Sft 7 ft.% C `i�
5a.Well Location:
f r�. ?,S�b(F1obe..i Meradr:�11 buboc- 7Y� ` a pt�i L
Facility;/Owner Name /� Facility ID & ft.#(if applicable)
),NAaha)r�Cs (2Ot/.L t J Mal IS E ciei 028,75 s. et , • !1
ijPhysical Address,City,and Zip +..��L_ ��
21.REMARKS
Het-)defso h c1G3oa y 55o 7 JUL 1 7 2024
County Parcel Identification No.(PIN)
56.Latitude and Longitude in de /minutes/seconds or decimal degrees: ItiEi;'i�_iD' �'^ ,
(if well Bald,one lel/longgis sufficient) g 22.Certification: D f��3 lrs
� t...4)
o4..z
d li/
Con ' r
6.Is(are)the well(s): QPrermanent 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 0.2C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 21Vu 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 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 nrrreslty..
For multiple byection or non-water supply wells ONLY with the same construction,you can
submit one form SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: (FF i (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For nwltipk wells list all depths if different(example-3 00'and 24100') construction to the following:
10.Static water level below top of casing: 20 . (ft) Division of Water Quality,Information Processing Unit,
If water level Is above casing,use"+" / 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. i 6 (in_) 24b.For Injection Wells: In addition 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 Mail Service Center,Raleigh,NC 27699-1636 Sm
13a.Yield(gpm) 3
Method of test Blowing-Rig 24c.For Water ppl9&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: sr DZ completion of well construction to the county health department of the county
where constructed
Form OW-I North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Ian.2013