GW1--04185_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 zOI�ES
FROM TO . , DESCRSPTION
Well Contractor Name ft 3 0 R —
NCWC 2028-A ft. ft
NC Well Contractor Certification Number 15 OUTER.CASING(for multi armed wefts)OR LINER(i ap�6ealie)
FROM TO DIAMETER THICKNESS MATERIAL
Ferguson's Well and Pump, LLC . C1 re. cj fro 6,-5 in. 27b,1AS ; rC5-1)2z/
Company Name ot3
16.INNER CASING OR TUBING(epermal dosed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 5Oa 1 ft ft in.
List all applicable well construction permits .e.County,State,7Varrarce,etc.) —
—
ft ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: PROM TO DIAMETER SLOT SOLE THICKNESS MATERIAL
❑Agricultural ❑ lic ft ft. in
❑Geothermal(Heating/Cooling Supply) DKirsidential ater Supply(single) it ft m—
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT -
PROM TO MATERIAL. ' EMPLACEMENT METHOD&AMOUNT
❑Irrigation C
Non Water Supply Well: ft- 20 n Concrete Gravity-How
❑Monitoring ❑Recovery it - ft ,
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediatiou 19.SAND/GRAVEL PACK(if aNpliicable)
PROM TO MATERIAL_ EMPLACEMENT METHOD
❑Aquifer Storage and Recovery 04alinity Barrier ft. -
❑Aquifer Test ❑Stormwater Drainage
—
ft ft
❑Experimental Technology ❑Subsidence Control ' r
20.DRILLING LOG(attain additional dents If nxsstasy)
❑Geothermal(Closed Luup) ❑Traces FROM TO DESCRIPTION II'TION(odor,hardness,soiurodt type,grain du,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) (-i ft )0 IL (t l/f`
I � y �
ft. C ft'
�
4.Date Well(s)Completed: �2 G9r2�/ Well ID# /) �� /(
—
Sa Well Location: r Ye ftft. S�) R r', r1,1 - C
G era( c iJkee le r ��1 ft y(S ft ft �'^'''rU� ��
Faci(ity/0wner Name. Facility ID#(if applicable)
—
f. ft
' Df- 41 (yc t•-(C. K.-d 0-)r rs (-4t. \ eQ R l 54 ft ft
Physical Address,City,and Zip 2L REMARKS 1
Or\pa15Qr• q65 -I1- 154'5 —
County Parcel Identification No.(PIN) it's :
Sb.Latitude and Longitude in degreea/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22 Certification:
&5'`' . .7, ) rKeT�� i' N CC>,` 3) /3� 3 ) ,r W ,, y/ �, sco/Al/ � L/��z�� � '` signature oi /' 1 ah
6.Is(are)the well(s): B1'nrmanent or ❑Temporary
By signing This form,I hereby certify that the well(s)was(were)constructed in accortlmice
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 QNu copy of this record has been provided to the well owner.
If this is a repair,fill ow brown well construction Mfornwlion 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 necessary.
For nadtiple injection or non-water supply wells O1VLY with the SOME construction,you can
submit ore form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 7 f'S (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if r i mat(esanple-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: G ' (ft) Division of Water Quality,Information Processing Unit,
If water level is above caring,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. - 6 On-) 24b.For Iniection 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,Uhaderground Injection Control Program,
FOR WATER SUPPLY WFI.T,S ONLY: 1636 Matt Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) A Method of test: Blowing-Rig 24e.For Water Simply&Injection well: 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 <�., 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