GW1--06851_Well Construction - GW1_20241115

• VI'a!,LiLi t. J1 I3 I %U l 111 111 fl .9 i K A➢ • For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: . • .•
[., A l }.� 14.WATER ZONES t
Bobby.W. POLLS FROM TO • DESCRIPITON
Well Contractor Name ft f y1) ft
. . . NCWC 2028-A It. R/0 it
NC Well Contractor Cc tincation Number 15.OUTER CASING(for Multi-eased tvdls)OR LINER(if applicable) . '
FROM TO DIAMETER ' I THICKNESS MATERIAL .
• Ferguson's Well and Pump,,LLC 0.. ft 7 3' ft • t S.in i60 AS Pecspd.2/
' Company Name . 16.INNER CASING OR TUB G(geothermal closed-loop) • •
C FROM TO DIAMETER THICKNESS •: MATERL4L
2.Well'Construction Peratit#: V �J o 67 a. ft ft
List all applicable well construction permits(Le.County,State,Variwice,etc.)
ft ' ft in
3.Well Use(check well use): 17.SCREEN •
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL • •
❑Agricultural ❑M cipal/Public ft ft. •in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft it in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL• EMPLACEMENT METHOD al AMOUNT
❑Irrigation . • 0 ft 20 ft Concrete Gravity-Flow
Non-Water Supply Well: • •
ft ft.
,❑Monitoring ❑Recovery' ' •
Injection Well: ft ft
El Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PAC!'(if applicable)
FROM. TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Bather ft • ft
❑Aquifer Test ❑Stormwater Drainage - '
fr. ft
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary) '
❑Geothermal(Closed Loop) ❑Trdeer FROM TO . . .DESCRIPTION(calor,hardness.sail/rack Npe,_grnln size.etc.) •
❑Geothermal(Heating/Cooling Return) El Other(explain under 421 Remarks) 0 ft ( 0 ft /t((MI
60 4.Date We Completed:/f(�Well TI# ft L O • ft S a 0- ."
II 7D ft 7 S. it. tA
•
Sa.Well Location: .
t. c • ft
7�f is ltfilt •
I(ri\ l�(t�T�PreCt1 ig,- •
ft ft lr
Facility/Owner l�me Facility lDr(if applicable) '" I x
(� / h fr. ft. , r,
a U nr-l?Ov1 V C rRt 9 r V-ene1.tysf�i�lA.�(R7Q a. ft ft 'NOV ! [�L4
Physical Address,City,and Zip
• 21.REMARKS . •
County Parcel Identification No.(PIN)
fib.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22,Certification: • . •
sufficient)(if well field,one lat/long is sufficient)
3s °a0'si, 52$ „ N �'at3y/7/ 7,cf2 " w G� /;-*--
Signature of tided Well Contractor. tit/0"V '
6.Is(are)the well(s): ermanent ur ❑Temporary • By signing this form,1 herebycer that the waft)was(were)constructed in accordance
b'��S f . tif'. ()
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: ❑Yes or C4IQu 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 1121 remarks section or on the back of this 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 injection or non-water supply wells ONLY with the same construction,you can
submit one form SUBMITTAL INSTUCTIONS.
9.Total well depth below land surface: • 2 its (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths((different(example-3( 200'and 2@100') construction to the foIlowing:. '+
10.Static water level below top of �l casing: /� (ft.) Division of Water Quality,Information Processing Unit,
If water level is above casing,use"++" e1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: ` _ 62 (in.). 24b.For Infection Wells: In addition to sending the fomi to the address in 24a
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) 3 O 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 U completion of well construction-to the county health department of the county
i 13b.Disinfection type: Amount: )7 oz. where constructed.
i
. • Form OW-I North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013