GW1--06825_Well Construction - GW1_20241115

WELL CU1NN.I.liU1:1111IN RECORD . 1 • .
For Internal Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information: • •
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Bobby W. Potts 14.WATER ZONES.
FROM TO DESCRIPTION
Well Contractor Name • ft. $.50 ft.
NCWC 2028-A .ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING(for nuiltkased*efts)OR LINER(if applicable)
FROM ' TO DIAMETER THICKNESS MATERIAL ...
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Ferguson's•Well and Pump, LLC 0-ft' 4 b " :1,7.5, fri. ,thi/257 fie-e5Dg_:, -1
Company Name 16.INNER CASING OR'SIBLING(geothermal elosed400p) • ,
FROM • TO • DIAMETER THICKNESS MATERIAL
2.Well Constritetion Pernilt#: Aorat-i -- (4:.)O 5 3 9 . it. . ft. , in. •
List all applicable well construction permits(Le.County,State,Variance,etc.) •
ft•
3.Well Use(check well use: • ,
17.SCREEN . .
. • Water Supply Well: " • FROM : TO , ' DIAMETER SLOT SIZE THICKNESS MATERIAL . ,
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OAcricultural ft
OMUI. :Pal/Public • .
OGeothermal(Heating/Cooling Supply) esidential Water Supply(single) . ft ft in:
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ClIndustrial/Commercial OResidential Water Supply(shared) FROM
ROUT • •
TO - MATERIAL. EMPLACEMENT MEIHOD&AMOUNI.
0 Irrigation •
0 , fr• 20 ft- Concrete 6ravityl-FlOw .: .
Non-Water Supply Well::. , • • • -
0Monitoring OR.ecevery . ft. ft- 1
- • . .
•.
Injection Well: ,ft. •ft
ClAquifer Recharge 0 Groundwater Remediatiou 19.SAND/GRAVEL•PACK Of applicable)
•' 0Aquifer Storage and Recovery, 0 Salinity Barrier ' FROM TO MATERIAL EMPLACEMENT METHODft. .
•
0 Aquifer Test 0 S tOrmwater Drainage ..,
ft , . . .
DExperimental Technology CiSubsidence Coritrol . ft .
20.DRILLING LOG(attach additional sheets if necessary)
OGeothermal(Closed Loop) OTracer - FROM TO , DESCRIPTION(cuter,hardness.soil/rock typergrein she,etc.) •
OGeothermal(Heating/Cooling Return). Dottier(explain under t;21 Remarks) o. ft- so . ft- . Clay ,
4.Date Well(s)Completed: )6/2,5/2,*ell UM . ' ca fr. 6 0
. 6'0 " 66 ft
• : i I
re elf
5a.Well Location: • ft. g . . .
G
! ' &_/11.1 to ; ii, :IC.Orge.•/-(441e,._ . 6 ft. '6 33-s ft.
ft. -
Facility/Owner Name Facility ID#(if applicable) • • . •
ft ft.
sa 1 ros.ker ts:1c44-c Or Le;iccsker 0817 q g ft. ft.
I •... ?i.-."1 i,...,*;:1'.-.7.1 i',..I ir'..2 j.. .• '
Physical Address,City,and Zip
• 21.REMARKS
'--- i tr-)C.C•Me •91A()61409/06 . . NOV 1 ;_. 2024
County ' Parcel Identification No.(PIN) • '
.......
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 77.Certification. L.:-.:-.;
(if well field,one lat/lorig is sufileient)
d ,_
5 8- I LIM gg°31 /5 t 0/.// W . , 0/R,s/zy
6.Is(are)the well(s): nt or OTemporary.01' ermane Signature of Certified Well Contractor' Date
' By signing this form,1 hereby certifr that the we/I(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards mid that a
7.Is this a repair to•an.existing well: OVes or EtIC-.7 . 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 INS 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. Youmay also attach additional pages it-necessary: •
For multiple injection or non-water,supply wells 014.Y with the same cons.true:lot:,you can
submit one form SUBMITTAL iNSTUCTIONS !
9..Total well depth below land surface: • m , (ft.) 24a. For.All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifrerent(example-3, 20 'and 2@1 00') construction to the following:
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10..Static watcr.level below.top of casing:. yr? . (ft) Division of Water Quality,Information Processing Unit,
If water level is above casing,rise"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter; v _ (in.)' ' Itb.For Injection Wefts: In additidn 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 censtruction Method: ROa ry. .. construction to the following: ,
(i.e.auger,rotary,ciable;direct push,etc.) . ,
Division of Water Quality,Underground Injection Control Program,
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FOR WATER SUPPLY*WELLS ONLY: / 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpin) 5 0 . Method of test: Blowing-Rig 24c.For Water Snooty&Injection Wells: In.addition to sending the form to ,
• the address(es) above, also submit one copy of this form within 30 clays of
131i.Disinfection type Chlorine • 1 ,
Amount OZ
1(0 completion of well construction'to the county' health department of the county
: • ' .•
I where Constructed.
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• ' Form OW-1.. . North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013
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