GW1--04147_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-ZO
FROM TO • , DESCRIPTION
Well Contractor Name ft 46 ft
NCWC 2028-A ft jc) ft
NC Well Contractor Certification Number • IS.OITFER'SING(for multi-cased wells)OR LINER(if appacdie)
FROM TO DIAMETER THICKNESS MATERIAL
Ferguson's Well and Pump, LLC 0 rt //$1 n ‘;A,j //,, - A r S pita/
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
q
p FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit N: a 3 -/)03 0 l ft ft in
List all applicable well construction permits(Le.County,State, raarre,etc.)
—
ft ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ipal/Public ft ft in.
❑
❑Geothermal(Heating/Cooling Supply) Et dential Water Supply(singly) ft ft k
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT —� -
FROM TO MATERIAL_ EMPLACEMENT METHOD&AMOUNT
❑Imga°°n - 0 ft 20 ft Concrete Gravity-Flow
Non-Water Supply Well: •
❑Monitoring ❑Recovery it ft —^
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft —
❑Aquifer Test ❑Stomtwater Drainage —
ft ft.
❑Fxperimeatal Technology ❑Subsidence Control ' r
20.DRILLING LOG(attade additional sheets If nocmary)
❑Geothermal(Closed Luup) ❑Tracer FROM _TO DFS('RIP1TON ten/ot hardness,sotl/roclt type,Rratn due,de.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) C ft ''.S ft C y
4.Date Well(s)Compkted:W V Well ID# ft ft u�
Sa.Wen Location: j �(^!L'( f t f l/ � �l d U f C.
e'Ol,i f^!v14! / r/ ft (� ft Gi'RGV� � .
Fac litytr Owner Name. / Facility EN(if applicable)
/3 ��,, Q/ ft ft
(/IH )/?GrY+t R V e . /,ilG,r1A.4/9a4 ft ft • ....t.%e.. �lr I.
Physical Address,City,and Zip Gle778 21-REMARKS Mr 11LO�4
tAnC(vr) 3( 94 i5 FL %'o
County Parcel Identification No.(PIN)
Sb.Latitude and Longitude in degrees/minates/sawnds or decimal degrees: D
(if well field,one hit/long is sufficient)
22.CertlfiGation:
�35°.3`/111` 58 " N iA ' (-/` 30;..C4AS W ' �� 1/(//tiA': 1-- /7/Ay
E ofCcMScd Wontea r
6.Is(are)the well(s): Er ermanent ur ❑Temporary By signing this form,I hereby cemify that the wall(s)was(were)constructed in accordance
,� with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 We!!ConstructionSt®rdards and that a
7.Is this a repair to an existing well: ❑Yes or QNo copy of this record has been provickd to the well owner.
If this is a repair,fill out known well construction it fonnation and explain the nature of the
repair rider#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 byectior or non-water supply wells ONLY with the same construction,you can
submit one forms ff SUBMITTAL INSTUGTIONS
9.Total well depth below land surface: I)\ (g,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 00'and 2@100') construction to the following:
10.Static water level below top of casing: 5-0 ' (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. Y 4 (in.) 24b.For Injection Welly: 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 Matt Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) /v Method of test: Blowing-Rig 24c.For Water Sunulp&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 7�i CZ 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 Quaity Revised Jan.2013