GW1--06828_Well Construction - GW1_20241115

W L+LL 1...U1V LIEU L.11U1V 1C➢L L:U1C1.➢ For Internal Usc ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES. I
Bobby W. Potts FROM TO DESCRIPTION
Well Contractor Name ft 20.0 ft
NCWC 2028-A it 270 ft I
NC Well Contractor Certification Number 15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
FROM TO • DIAMETER ' THICKNESS MATERIAL
Ferguson's Well and Pump, LLC 0,-.ft So/ft , a,9ltr. 216/0 itcp,eZ t
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
FROM TO DIAMETER , THICKNESS ' , MATERIAL
2.Well Construction Permit#: a()aGt 3 Va I. In ft ft. 1 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 ❑Mul• 1pal/Public
❑Geothermal Heatin^Coolie Supply) esidential Water Supply(single) ft ft in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18,GROUT •
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT .
❑litigation . ft ft'
Non-Water Supply Well: 0 20 Concrete Gravity-Flow
❑Monitoring ❑Recovery ft. ft. -
Injection Well: ft. ft .
❑Aquifer Recharge ❑Groundwater Remediatiou 19.SAND/GRAVEL PACK(f applicable) :
• ❑Aquifer Storage and Recoymy ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD _
ft ft ,
❑Aquifer Test ❑Stormwater Drainage
ft. ft .
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer PROM TO DESCRIPTION(color,hardness.soil/rock tvpeigtnin size,etc)
❑Geothermal(Heating/Cooling Retum). ❑Other(explain under 421 Remarks) 0 ft 30 ft ((ay
'
4.Date Well(s)Completed: 7 y 25 Well DM
0 ft. Cf$ ft Su S G
5a.Well Location: (( c/S ft S ft. i)JM C /C
5a ft. 30S ft. Plato-,(Alt-
lOngk.1 C'-,, (<<aa P-) ft. ft
Facility/Owner Name Facility 1Db(if applicable)
c.� ft ft. I'," ` . >
it C i106 f o U O W tz, fL{�Yt 4-r1 ;lc 71 I ft. ft • ... 'x
Physical Address,City,'and Zip 21.REMARKS ill V t' :• •/(J 2d
IPr 0 OA 10-e- LP a 5(04 0 s a 5atat, .
County Parcel Identification No.(PIN) it'"' -,•0 L: .,.-
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one tat/long is sufficient) •
7
3s� •
3>1'T,7�'' N js7+a/6� (, 0�,�°Z " W V /s tore ell Contractor D
ancnt or ❑Temporary 6.Is(are)the well(s): erm By signing.this form,I hereby certify that the well was(were)constructed in accordance
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 0110 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 this form., 23.Site diagram or additional well details:
8.Number of wells constructed: / You may use the lack of this page to provide additional well site details or well
construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you,can
submit one fame SUBMITTAL INSTUCTIONS. '
•
9.Total well depth below land surface: 30 5 - (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@100') • construction to the following:
10.Static water level below top of casing: /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: ` _ 6 (in.). 24b.For Injection Wells: In addition to sending the form to the address in 24a
above, also submit a copy of this farm within 30 days of completion of well
12.Well construction method: Rotary construction to the following:
(i.e.auger,rotary,cable,'direct push,etc.) 0
Division of Water Quality,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: / 1636 Mail Service Center,Raleigh,NC 27699-1636
I
13a.Yield'(gpm) /.5. Method of test: Blowing-Rig 24c.For Water Supply&Injection Wells: In addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Chlorine Amount: QZ, completion of well construction to the county health department of the county
where constructed.
Form OW-I'-. North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013
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