GW1--06868_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: i'
•
Bobby W. Potts 14.WATERZONES : • . , : •:.i•
Y PROM -TO •. • DESCRIPTION
well Contractor Name ft . ..3elD . I
•
NCWC 2028-A •
NC Well ConhacterCatifiea6oaNumber - . . 15.OUTERCASING(formmlH.i�ed nails)OR LINER Of )
Ferguson's Well and: Pump, LLC '. FROM � TO . � DIAMETER TRIMNESS . MATERIAL
•O • , •5'7: .5:j VA1:12.S: PVC51)2 1_
Company Name 16 INNER CASINGO$ G(e4othma1doaed400p) ' . .
r� FROM TO' ' •'DIAMETER. THICKNESS• MATERIAL
2.Well Construction Permit#: oZ O -bag q S. 8 ft iv<.. .
List al applicable well eaabueton pamlts(Le County,Statg7'ariarug eta)
• ft ft. im ,
3.Well Use(check well use):. . 17.SCREffiN•
Water Supply Well: FROM• TO DIAMETER SLOT SIZE T ICICNE S MATERIAL
❑Agricultural ❑ ctpal/Public ft. ft in
•• ❑Geothermal(Heating/Cooling Supply) ' "ddential Water Supply(single) m ' . • _
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROITT :
FROM TO • MATERIAL FMPLACIDIE 1TMETHOD&AMOUNT
❑Irrigation . .
Non-Water Supply Well: • 0 ft '20. f Concrete . Gravity Flow
OMonitoring ❑Recovery ft. ft. V.
Injection Well: fr. ft '
- ❑Aquifer•Recharge ❑Groumdwater Remediation - 19.SAND/GRAVEL PACK CdamilfieaHe)
•
❑A StFROM TO MATERIAL'••' :•EMPLACEMENTMwIROD _ .
quif.er Storage and Recovery ❑Salinity Bather
R. it
❑Aquifer Test ❑Stomlwater Drainage • • .
❑Experimental Technology ❑Subsidence Control �• ; .. o
20.DRILLING LOG-(attacb additiamlAnts ff ar9) •
QGeutheummal(Closed Luup) DTIEGer • PROM TO . •DESCSup4 TION(caIet hardness,rolUtodt ism loin site,da)
OGcothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft 3 S- .it . •• C(a, . •. • . . .
4.Date Well(a)Completed:74 ay Well MN 3 S S ft..• i Sll�
5a.Well Location. 1
0 hiy1,49 tieve_.,,e, .
S7fL 70,3ft . - . , 6-4,cwtf'e .
Faeility/OwucrName. FaciiityID#(if applicable) R..a �_ • y? ;'' . .
ft rt. ti Il ri �!'ti..'�..
- .Cj,�j 5itarejn 12 . 1t#4 Vic' 0. ft. .it N.O.V,'1 ;:..'nj�.
l'ltvsieal .City,and Zip 21.REMARKS
b& (9. SS52a 2Cto z l
: r:.:,, P_,- - :•; r�.F- -.
.,. :ter:"••
County Parcel ldeatifeatioa No.(PIN) i ""‘,'"r `-'"
.
' S.Latitude and Longitude in degreeoh inutes/seconds or decimal degrees: - . r , • . . . ' -
(if
well field,one letAemg is sufficient) 22.'Cert fieati ;t
•
3.S° Yh y0 . N tz° AV`3A•�? Y(4 .w W.
t '''.7i/53
r_
signature of .,••ed Well Cont acto . • Cc
6.Is(are)the well(s): fdPenuaneat or ❑Temporary g3,signing font;1 hereby.eerr ,dat:the well(s)was(were)caristrctad to aecoraor:ix
.with 15A NCAC 02C.0100 or 1SANCAC 02C.0200 Fell Consdneoim Stmrdrnds and that a
7.Is this a repair to an.existing Well: [Wes or 131u copy of this recordhas beep Moviabdto the.well owner..
IfthLsts a repair,fill cad brown well construction bfonnation andeaplain the nature of the
• repair under#21 remarks sectiono•onthebaatofthtsform. 23.Site diagram or additional weldetain
Yon may use the back of this page to'p�rovide additional well site details or well
8.Nu tuber of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple WecU ,ornar-watersupplywellsONLYwith the same construclran,you can '
submit orefa,na • SUBMITTAL INS°TUCTIONS . . .
9.Total well depth below land surface: 70 S . (ft.) 24a. For All Wells: .Submit this form within'30 days of'completion of well '
Formuldple wells list all depths(ft0,fervrt(sonde!-3@200'and2®100) construction to the following: 1 i . • . .
)
rf
10.Static water level below top dewing: - Ad - : (g) Division of Water Quality,Information Proceubg Unit,
lfwaterlevel is above casing use"+" 1617 Mail Service neuter,Raleigh;NC 27699-1617
li i
11.Borehole diameter. f_ (in.) - 24b.yo,.7inieation Was: In addition to sending the form to the address in 24a
above, also submit a copy of this fdran within.30 days:of completion of well
12.Well construction method: ROtary construction to the following: 1 ' .
(i.e.auger,rotary,cable;direct push,etc.) ' • '
. Division of Water Quality,Underground Injection Control Program, .
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service Center,Raleigh,NC 27699-1636
132.Yield(gm) i ' McHmod of teak Blowing-Rig .24c.For Water Samniv&Intention We�Ilr.'In addition to sending the form to
the address(es)above, also submit,one copy of this-form within 30 days of
13b.Disinfection type: Chlorine Amount; (,6 OZ. completion of well construction to the Icotmty health depai1ment of the county
,where constructed I .
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Quality . . . ' .• . . Revised Jan.2013 •