GW1-2022-03217_Well Construction - GW1_20220311

WELL CONSTRUCTION RECORD for Internal'Use ONLY:
This farm can be a_ood Ear single Of midtiplc Wells
1.Well Contractor Information:
14:WATE1t;TANES
Chris Ruffer FROM TO I Ir"F.SCRIF"ON
Well Contracler Namc ft,
4223 A 1L fL i
NC Well CommaorCertiftation Nwaber 15:A1!f1 R'ICeCSiyCi farm4fal eased*cFlf OR 1dLYf R B=>t IIcab
FRMI TO PEANIETER THICKNESS ]MATERIAL
SAEDACCO Inc IL IL ia.
�1„p;mp Nags - -- - >i6:Q�3VEIF:CASING OFt TU6' G `' tset$iat2lo�e�aari '
FROat TO I DIAMETER THICKNESS MATERIAL
2,Weil CA"Str'uction i omit : 0 ft. 45 ft 6 sch 40 PVC
fist all appviinnble rrfl prnnitr rr_r..Carntv..gtp e.Variorrce.frl'Etda4 Fir.) rt' tt ar
3:Wadl Use(ehc.diwell usc):
Water Suppi•W4gft room 70 MA(w1I;7Rg SrAT5iU I 7NICK1ISS I MATKIt1At•
OAgricultuml OMunicipalo?ublic 65 It, 45 ft, 6 iti 020 SS
OCkothetnial(ieatingfiCooliog Supply} OResideuMl grater Supply(single) rL (L is
Olndustrialfcommercial OResidendal Water Sitpph'ishared) �1 ROIFl;::..
FROM TO NATERM EMPEACTIWENT]FEMOD&AMOUNT
131digation 0 ft. 39 f., Portland Trim
Non-Water Suppfy Well: rt.
0Monitoring 55Itccor
Injection Well: ___ _- __ _ fL tL
0AtluifcrRcchargc §1G9trndtttfcrRelncdialiaarr 14:;SA1V11!'CitAtEL PACK FN
Tc►__...-. -DfAURtat,- _ _ _ tali)n rYT tMw�rw
AAquifer Storage and Recover)' []Salinity Barrier vtt0ltr Oo
70 fL 42 fl, Sand 3
0 Aquifer Test 13Stounw-ater lhainagc ft. ft.
[]Experimental Technotogy CISabsiamc Contrat
34:DRI1.1.1NC 1)OG'(aitae6 adrli41aria161icefs T r�ecesfan}
OCetitltemtal(Closed iatap} OTrdeet FROM I TO aEscirrrrlO� eabnnaNnun wRmert d�rF ekl
OGeotitemual(dleatil )Goo' ftetum) OOtller( in ont)er t#21 Retroae s) (L M
ft. fL
4.Date Wells)Completed: 2-3-2022 WdJ I]D#EW-52 See Gpp s note$L
Sa,Well Locatirtn: fL fL
Chemours ft, ft. MAR 1 202.9
Faeilitp Ourner Name Facility IM(if applicable)
ft. rL
1248 Bill Hall Rd White Oak, NC 28399 Cumberland C, rt. ft
White Oak, NC, 28399 PlivsirnlAddmss.City.mWZip 2tsitl�AtRitI5,
Cumberland 70-65 is a 6 in SS sump
Comely Nrce1 It$:ctlifieadwnJNo.(PIN)
5b.iirtitrrdc and F onLritude in de�nces�nritruteslsecunds Qe decimal dcbrecs: 22.Crertifrcation:
difwelt fKW Ofte 1,M00tt$is StdfieiEr�t) Chris
++ ,�� {�
>` �} _ �. h ri S Ruff_e r 2/3/2022
Signal m of QrtJfted Well Centractar Date
6.Is(are;)the twell(s): NPerinaneat or OTeinporar}
By signing thiY farm,l lnerebf'certify rJJ{Jlr the 14'Fpll,YJ N7'S fV.YrIJ CG42!'lflf{•fe(p IR 8YY'O/dlfnre
with 15A NGAC 02t:.0f 0n or 15A NCAC i-C.02M Well L'nmmorrii n Standards and rhat a
7.Is this a repair to an existing well: Wes or NNo cope nft1+±•rrfnnl hna)Kerr rinnirh d ro r�r n+ll.n4hrr,
ljrNs'is a repair.fill for.tni iwr wtf twutr Mow hr/ortnatkm marl explabn rice narare rf the
repair ander#21 nnmorLr srx-ion or on rho bract of rhis/ornr. 23.Site diagram or additional well details:
You may use the back of this pale to 0I011-de additional well site details or tiweit
8.number of wells Iona Ttcted: 1 construction details. You may also attach additional pages if necessary•.
For.nusldple injection or raaoi-xarer sarpplrwells 0JVLV with fie snare ceirsrrme don,you eon
nif,a it one form. SUBbIITTAI,IMUCTiONS
9.Total vwelldepth below land surfacr_ 70 f1Y,) 24a.. For All Welly Submit this fann within 30 d.'R•s of aorirptetion of mll
For malfiple wells liar all deprhs lfdi erei t(e avTle-J@2AP'oral toff 100 construction to the foltoning:
10.Static seater level below top of casing:. (D,) Division of Water Rescuttet,Information Protessinp,Unit,
11 ramtef leVei iS rti10Pc rr'al(fi$,GX'•+" 1617 Mail Service Center,Raleigh,NC 276"-1617
11,Borebole dinancta-10 in ( ) 24b.&I InireHon Wells QN1 Y: In addition to sending the fo.m.to dte addrem in
24a above. also submit a copy of this forth within 30 days of completion of well
12,Well mustrHetion metbod.: Sonic COnslnlctinn1atltc:fdll0Wittg_
(i.e.&art.rotan.cable,dirm gash etc.)
Division of WaterResou:rees,Underpvtrnd injection Control Program,
1636 Mail Stmicc Center,Raleigh,WC27699.1636
FOR WATER SUPPLY WELLS ONLY,
13a.Yiidd(gent) Method of test., Z4c.For Water Sti ply A lWoction Wells:
Also submit one copy of this form twithin 30 days of completion of
13b.Disinfection ggae•. Amount �. %ell constriction to the courtly health department of the ccninty where
construcNxl, I
Foun GW-1 Noah Camlins Cxqnfttcnr of Eaciralumm and Nanval Resow ees-Division of%later ResotrXes Rin iced Atagu5t V)13