GW1--06852_Well Construction - GW1_20241115

VVL'Ljtn f.U1V011SUC,11U111 1itt.UICILJ For Internal Use ONLY: ,
This form can be used for single or multiple wells t • •
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1.Well Contractor Information:
14.WATER ZONES I
Bobby W. Potts FROM TO DESCRIPTION •
Well Contractor Name ft /30 ft.
NCWC 2028-A ft /70 ft 1
NC Well Contractor Certification Number 15.OUTER CASING(fir multi-eased'wells)OR LINER(if applicable)
•
FROM TO DIAMETER THICKNESS. MATERIAL
Ferguson's Well and Pump, LLC 0:: It gq tx Gas ! 'r' 2f S petsj. ,Z'l .
Company Name 16.INNER CASING ORT ING(geothermal dosed-loop)
FROM TO DIAMETER THICKNESS •' MATERIAL
2.Well Construction Permit 6: e ()a(4 - G Va ( 7 ft ft . in.
List all applicable well construction permits(i.e.County,State,Variance,etc) ft. ft
3.Well Use(check well Use): 17.SCREEN .
Water Supply Well: - FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft in.
❑Agricultural ❑M ipal/Public _
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft ' in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD.4 AMOUNT
❑Itxigation . 0 ft 20 ft Concrete Gravity-Flow
Non-Water Supply Well:
❑Monitoring °Recovery ft ft.
Injection Well: ft ft
❑Aquifer.Recharge 0 Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
❑Aquifer Storage and Recovery 0 Salinity Barrier FROM TO MATERIAL EMPLAC NTMETHOD _
ft ft
0 Aquifer Test ❑Stormwater Drainage
ft ft.
❑Experimental Technology ❑Subsidence Control -
20.DRILLING LOG(attach additional sheets if necessary)
❑Geuthemal(Closed Loop) ❑Trace• FROM TO DESCRIPTION(color,hardness soil/rock type,_gram slxq etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 52I Remarks) D ft {f0 ft a/!,
4.Date Well(s)Completed: li��/n�(/ Well DE: f(fi ft C� ft Sagd WC
5a. gift
Well Location: S0 ft. $q [t ✓1 _ "fr
/_ /mac
nn g ft 1/4)? e-
7)nh a l l( har�1 • . ft • ft .
Facility/Owner Name Facility1D#(if applicable) ,.
ft ft t..... • .?—^:-• \
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Lig I�rO 1 %
N.0k 6LA t UL Mks^ f9 poll fr. ft. , .. , ...
Physical Address,City,and Zip 21.REMARKS _NI IV 1_ :: % )4
riDltnChnl�j� & asvtO5asOowt .
County Parcel IdentificationNo.(PIN) Ir;i0:?,'.;. ,r . - T;tj...IP,a
RiS B+
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: -- _
(if well field,one lat/long is sufficient)
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R/Peg" • .
..1As,/,_:2_„z__
SignatY.+fed Well Contractor Da
6.Is(are)the well(s)::8Pc►•manent or ❑Temporary By Szgning this form,I hereby certify that the well(s)was(were)constructed in accordance
with 1SA 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 t3No 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:
8.Number of wells constructed: / •
You may use the back 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 form 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- Qa 200'and 2C100`) construction to the following:
10.Static water level below top of casing: / (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: t+ .r 6 (in.). 24b.For Injection Wells: In addition to sending the fonn to the address in 24a
Rotary above, also submit a copy of this form within 30 days of completion of well
IL Well construction method: construction to the following: I
(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 Ceniter,Raleigh,NC 27699-1636
13a.Yield(gpm) 3 0 Method of test: B lowing-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: 6 QZ, completion of well construction to the county health department of the county
where constructed.
a- S
Form OW-1 North Carolina Department of Environment and Natural Resources-Division of Water Qutili ty Revised Jan.2013