GW1--06832_Well Construction - GW1_20241115

VYLtLL t.t.)1V611iU1..1101' KLLUKI) For Internal Use ONLY:
This form can be used for single or multiple wells . I
1.Well Contractor Information:
24.WATER ZONES I •
Bobby W. Potts FROM TO DESCRIPTION
Well Contractor Name ft a90 ft
NCWC 2028-A . ft. 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 t' °-ft 1/5 ft, S ,aS in 2,/t,//eV /i c S t)oaf
Company Name 16.INNER CASING OR TUBING(geothermal closed400p) •
FROM TO DIAMETER THICKNESS . MATERIAL •
2.Well Construction Permit#:• a aai-c - b a Li�)P7 ft ft in.
List all applicable well construction permits(t.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
❑Agricultural '❑Municipal/Public ft ft. in. _
ift❑G ermal(Heating/Cooling Supply) ❑Residential Water Supply(single)
18 ft in
dustrial/Commercial ❑Residential Water Supply(shared) ,GROUT
FROM TO • MATERIAL EMPLACEMENT METHOD&AMOLTT
❑Inigation
Non-Water Supply Well: ' O ft 20 it Concrete Gravity-How
❑Monitoring ❑Recovery' ft • ft.
Injection Well: ft ft
❑Aquifer,Recharge 0 Groundwater Remediation ' 19.SAND/GRAVEL PACK.(if applicable) '
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD —
ft. ft
❑Aquifer Test ❑Stonnwater Drainage
ft. ft.
[Experimental Technology 0 Subsidence Control •
20.DRILLING LOG(attach additional'sheets if necessary)
❑Geuthetmal(Closed Loop) ❑Tracer FROM To DESCRIPTION(color,hardnr_+s.soil/rock ,g nln sire,etc.) "
❑Geothermal(Heating/Cooling Return) • ❑Other(explain under 4'21 Remarks) D ft p ft Clay
4.Date Well(s)Completed: �D 0 f/Well ID# P'
3a ft' Y& r` So 12G
5a.Well Location: `7 ft �(� it " /i���DC lC
•
•n r^,�r4, f] / �j� /�L 6 7(C
.101 1 1"` Cli(in - 01 CluiGA. y5 ft So, ft �A tilt/ � :
FacilitylOmerName Facilityll (if applicable) ;
y� y� , G G ft ft - '
iiO(�.S /flIn A541C-Vtiti 'IVIc. - O DG Li fr. ft t ...<
�� :i
Physical City,and Zip 21.REMARKS NO V 1 ?'`. 2024 .
nrnrnb . q 7307q 7(5JrnQ2` ;.
County Parcel Identification No.(PIN)
51.Latitude and Longitude in degrees/minute's/seconds or derim41 degrees: 4redW " k
tification:
(if well field,one lat/long is sufficient)
35/ 913/bef'' N 5v, y/ '33, g wv / W ell Contractor a
6.Is(are)the well(s): iflPCrtnancnt ur ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 1 SA 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 rd‘ 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 t21 remarks section or on the back of thii 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 multiple itgection or non-water supply wells ONLY with the same construction,you cm •
submit oneform. SUBMITTAL INSTUCTIONS
9,Total well depth below.land surface: • ,5 S (ft.) 24a. For.All Wells: Submit this form within 30 days of completion of well '
For multiple wells list all depths if diferent(example-313200'and 2@100) construction to the following:
10.Static water level below top of casing: SO • (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: ti: 6) (in-)' 24b.For Injection'Wells: In addition to sending the form to the address in 24a
Rotary above, also submit a copy of this.foim within 30 days of completion of well
•
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) I "
Division of Water Quality,Underground Injection Control Program,"
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) /S Method of test: Blowing-Rig 24c.For Water Supply&Injection Wells: In addition to sending the form to
the address(es) above, also submit one.copy of this form within 30 days of
Chlorine Q • oZ completion of well construction to the county health department of the county
136.Disinfection type:. Amount: �v where constructed. "
Form OW-I , North Carolina Department of Environment and Natural Resources-Division of Water Quality Revised Jan.2013 "