GW1--06824_Well Construction - GW1_20241115

WE'LL CONS'IRU C'FION RECORD For Internal Use ONLY: • 1
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This form can be used for single or multiple wells -
1.Well Contractor Information:
BobbyW. Potts 14.WATERZONES I
DESCRIPTION
Well Contractor Name ft 2 ya ft I
NCWC 2028-A ft y3o ft.
NC Well Contractor Certification Number 15.OUTER CASING(formulti-cased wells)OR LINER(if applicable) _
FROM TO . . DIAMETER THICKNESS' 'MATERIAL
Ferguson's Well and Pump, LLC ft ft in.
D- 7� kt� 2/tii��S/�pcSD22,
Company Name- 16.INNER CAS G OR TNG(geothermal closed-loop) .
I, ' FROM TO DIAMETER THICKNESS• ' MATERIAL
2.Well Construction Permit#: al/Ll ao o.Lk' o 418.9 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
ft ft in.
['Agricultural ❑M cipal/Public
❑Geothermal(Heating/Cooling Supply) f eesidential Water Supply(single) ft ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) '1&GROUT
FROM TO MATERIAL EMPLACEMENT METHOD Sc AMOUNT
['Irrigation 0 ft. 20 ft Concrete Gravity-Flow
Non-Water Supply Well:
OMonitoring ❑Recovery ft ft.
Injection Well: ft. • ft
❑Aquifer Recharge 0 Groundwater Remediation 19.SAND/GRAVEL PACE(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery 0 Salinity Barrier ft ft --
[Aquifer Test ❑StormwaterDrainage It. It.
DExperimental Technology 0 Subsidence Control '
20.DRILLING LOG(attach additional sheets if necessary) '
❑Geothemal(Closed Luup) OTracer FROM TO DESCRILTTION(color,hardness,soil/rock type,grain size,etc) '
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) V' ft �6,Q ft �'la ,(/�/
�ir�/ !X ft ! ft $1 Grd7!/-5l�IICG
4.Date Well(s)Completed: n /� Well BM
5a Well Location: 70 ft 76 ft /3jrd/VC/(C
(� (1f Nit( l�Pa.Itk Cuve Ccn4' 7t'0 ft ft 6�S U`i�W�i
Facility/Owner Name Facility ID#(it-applicable)• ft ft
3$O febard__ 2c( pck at lc 98 $O(e ft. ft
Physical Address,City,and Zip •
21. EbR�S rQ` JZ^
-
hcom 9(. 37 I$a SS
County Parcel Identification No.(PIN) Irif.7.7,.4. ..?a. _ '`;3.
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22. 1
gr
22.Certification:
(if well field,one lat/long is sufficient)
)
33 O O 3v t 7/yr' N 3 �' 1 l e// l' w ‘40/(1'""
Signature of ertified Well ntractor a
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6.Is(are)the well(s): 12 ermanent or OTeinporary By signing this form.I hereby certify that the well(s)was(were).constructed in accordance •
' • with I SA NCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or fdPio 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 thisform. 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 iryection or non-water supply wells ONLY with the same construction,you can '
submit one fonn SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: DS (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3 200'and 2@I00') construction to the following:
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10.Static water level below top of casing: -50 (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: i♦ _W 6 (in-). 24b.For Infection Wells: In addition to sending the form to the address in 24a
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Rota above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ry 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
13a.Yield(gpm) Method of test: BIowing-Rig 24c.For Water Supply&Injection W
1 t Wells: In addition to sending the form to
n'' the address(es)'above, also submit tine copy of this form within 30 days of
' 13b.Disinfection type: Chlorine Amount:- __�7 QZ, completion of well construction to the county health department of the county
����TTT where constructed. - •
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Form GW=1_--. North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013