GW1--06855_Well Construction - GW1_20241115

WELL CONSTRUCTION RECORD For Internal Use ONLY:
•This form can be used for single or multiple Wells
1.Well Contractor Information: •
'
Bobb W. Potts • 14.WATERZOINES ••
Y FROM TO • r DESCRIPTION •
Well Contractor Name ft. y!F/ft I . .
. NCWC 2028-A ft. ft I
NC Well Co agorCeztiicalion Number • (formi wells)OR LINER(ifa )
. FROM TO DIAMETER .THICKNESS MATERIAL
Ferguson's Well and Pump, LLC 7 ft t 3 � f,j2-' 2/6t/e15' S p c' i
pa • .
' Comny iName '16.INNER G OR closed-loop).
FROM TO D THICKNESS MATERIAL
2.Well Construction Permit#:. gOd 3 - b 6 5 n /2 ft ft. in.
'List all applicable well construction permits(I t County,State,Variance,etc.) Y -
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 ❑Munn' blic
❑Geothermal(Heating/Cooling Supply) esrdential Water Supply(single) ft ft ill.
. ❑Industrial./Commercial ❑Residential Water Supply(shared) 19.GROUT , . -
• FROM TO ' MATERIAL ' EMPLACEMENT METHOD&AMOUNT
Oh-ligation
Non-Water Supply Well: •- N. 0 ft. 20 ft Concrete Gravity-Flow
OMonitoring ❑Recovery ft. ft • . •
Injection Well: ft. • ft. .
❑Aquifer-Recharge • C Groundwater Remediation 19.SAND/GRAVEL PACE of applicable) .
er Storm a and FROM. TO MATERIAL . —
EMPLACEMENT METHOD
❑A quif g cry ❑Salinity Barrier -
❑Aquifer Test ❑Stormwater Drainage '
ft ft
❑Experimental Technology ❑Subsidence Control P
• 20.DRILLING LOG(attach additinmal sheets if> ry)
❑GeuWcrmal(C1ost d I oop) OTracer FROM TO .DEStRIPTIONiodor,hardness,soll/rock type,grata site,eta)
❑Geothermal(Heating/Cooling Return , ❑Other(explain under 421 Remarks) 0 ft .54C7 It • ( a`/ .
4.Date Well(s)Completed: /7 �y Well 1D# �U ft .ft � � j
U
Sn.Well Location:.. /„'-7/ 3 ft.
ft- 7) ft rcc/C .
jla)� I. . 0� r Et `�/fJ ft. '/1 ft , � �IC
! ft •
Facility/Owner Name. . Facility D#(if applicable)
ft. ft '''i4[' P.7 1. ----.
t�QO (J()rawft S lbri✓L CAncl lt.r 7j.� ft ft
Physical Address;City,-and Zip 21.REMARKS 'NO V a .: 2021
wn COrh be• • e&q(C la(e54 ,0
County Parcel ldentiScationNo.(PIN) ;Ii,....,..._.. .: . WR:?,
•
Sb.Latitude and Longitude in degrees/minutes/seconds
or decimal degrees: • - d V
(if well'field,one,lat/long is sufficient) 22 Cettiiication.
ffi
3S e5/` 4�',5;2 /IN . .1 0.V3 e2' W &4V4 ' %
Vzixr____
Contractor
6.Is(are):thewell(s): C+�P'trmanent. 'or ❑Temporary . •• Sy stgwrK this form,I hereby certify that the well(s)was(were)constructed in accordance
• / with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is ibis a repair to an existing well: ❑Yea or E�No • copy,of this record has been prnvidd to the well owner.
If this is a repair,fill out Imovm well construction b forinalion and explain the nature of the '
repair rider#21 remrarks section or on the back,of thisfann. . ' 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.
Fornmltiple Intention or non-water supply wells ONLY with the same constrrecdion,you can
submit one form. SUBMITTAL XNSTUCTIONS
9.Total well depth belowland surface: /A: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: 1 '
10.Static water level below top of casing.: • '7 d " (ft) Division of Water Conakry,Information Processing Unit,
If water level is above casing;use"+" 1617 Mail Sssvi=Center,Raleigh,NC 27699-1617
11.Borehole diameter. '- . 6 Om) 24h. +Lr"fn,e�jo Wells: In addition to sending the form 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: I construction'_o h^c following: i-
(i.e.,auger,rotary,cable,direct push,etc.) 1
a Division of Water Quality,Underground Injections Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Cent er�,Raleigh,NC 27699-1636
13a.Yield(gpm) 9.,ii . Method of test: Blowing-Rig 24c.For Water Supply&Injectien dells: In addition to sending the form to .
the address(es) above, also'submit one copy of this form within 30 days of
• Chlorine VA Oz. completion-of well construction to the county health department of the county
13b.Disinfection type: Amount:
where constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Quality Revised Jan.2013 •