GW1--06793_Well Construction - GW1_20241114

W LLL 1.U1.1 11(0 LA!.1Uly KELL:li dlj For Internal Use ONLY: •
This form can be used for single or multiple wells I) ,
1.Well"Contractor Information:yt al
14..Bobby W. POLLS FROMWATER ZONES • DESCRIPTION •
Well Contractor Name ft /ro ft.
NCWC 2028-A ft 39) ft I .
15.OUTER CASING(for multi-casediwells)OR LINER(if applicable) .
NC Well Contractor Certificationlvumber
FROM TO DIAMETER' THICKNESS . . MATERIAL
Ferguson's Well and Pump, LLC .a....ft 7A . ft $ - /47 ,7ec 'p/Lz/
Company Name _ UB 16.INNER CASING OR T G(geothermal dosed-loop)
\ FROM . TO DIAMETER THICKNESS , MATERIAL '.
2.Well Construction Permit#: VS -a0a LA --:()'5 5 ft ft. • I. in. .
List all applicable well construction permits(i.e.County,State,Variance,etc.)
ft ft .
F 3.Well Use(check well use): 17.SCREEN
. Water Supply Well: -FROM TO • DIAMETER I. SLOT SIZE THICKNESS .MATERIAL. •
ft ft
' " ❑Agricultural ❑Mu 1 /Public
❑Geothermal(Heating/CoolingSupply) esidential Water Supply(single) ft ft in.
❑IndusttiaUCotttmercial ❑Residential Water Supply(shared) 18.GROUT -
FROM • TO MATERIAL EMPLACEMENT METHOD&AMOU'[cT-
❑lriigation 0• ft . .ft . . . .
- Non-Water Supply Well: 20 Concrete Gravity-Flow
❑Monitoring ❑Recovery ft tt •
Injection Well:' ft. •ft "
❑Aquifer Recharge . . 0 Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable) :
•
❑Aquifer Storage and Recovery 0 Salinity Battler FROM To . MATERIAL EMPLACEMENTMETHOD
ft ft
❑Aquifer Test ❑Stormwater Drainage
ft. ft
❑Experimental Technolocv OSubsidencc Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loup) ❑Tracer FROM • "TO 'DESCRIPTION(color,hardness,soilfrock Lvpe,_gt•n1n she,etc)
• ' ❑Geothermal(Heating/Cooling Return) ❑Other(ea-plain under 4'2i Remarks) Q ft S 0 ft I elaY
)n '7lI 56 ft. 6 S� ft SG�s?S
4.Date Well(s)Completed: (O/ 7 A y.Well DM
t ft.
•
' 5a.Well Location: 7� filr
I �� �QC� •
ft ft J
WIT . �r� , tv •
Oic, (A.It_c CCnS()tt:tr -t.,-,LLC. - - ft . ft.
Facilit1OwnerName • FacilitylDR(if applicable) ft ft ` °,-. _ _ -:? u,-,Jam;
• AScc.trl o n `!G.(let 1.o4-a(.( -i fl 5Qfl,t ll( agiq),. ft ' ft NOV 1 / 2024
Physical Address,City,and Zip r21.REMARKS
\ ecctor5or ' g5a9[iig35acl .
County Parcel Identification No.(PIN) r'"`t '`.J 5
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification •
(if well field,one 1at/long is sufficient)
j
3.S° dJ37e 47P:8r� N $A°36'S,3 �j�, w � � R �
Sinnature of C Bed Well Contractor Date ' •
6.Is(are)the well(s): ermanent or ❑Temporary ' By signing this fornt,I hereby certify that the wells)was(were)constructed in accordance
with ISA NCAC 02C.0100 or 15A NCAC,02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: DYes or nilti 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 wader:21 remarks section or on the back of this form. 23.Site diagram or additional well idetails: •
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 infection or non-water supply wells ONLY with the same construction,you can SUBMITTAL INSTUCTIONS
submit onefornt
9.Total well depth below land surface: Y" (ft.) 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 l 00') construction to the following:. 1
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10.Static water level below top of casing: VD (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service-Center,Raleigh,NC 27699-1617
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11.Borehole diameter: t+ _ 6 (in.)' 24b.For Infection Wells: In additiou.to sending the-form to the address in 24a
above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Rotary • construction to the followng: - - -
(i.c.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
t
jep Blowing-Rig24c.For Water Supply&Injection Veils: In addition to sending the form to
�S Method of test:
m)
13a Yield the address(es) above, also submit'one copy of this form within 30 days of
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13b.Disinfection type: Chlorine Amount: QZ, completion of well'construction to the county. health department of the county"
• where constructed. i
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Form OW-1, North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013