GW1-2022-03218_Well Construction - GW1_20220311

WELL CONSTRUCTION RECORD For harnal Use ONLY:
This form can be asod for single or midtipk wells
1.Wdl Contractor Information:
Chris Ruffer IFRO;rt trtS('rut=TaU�
Well ConarectoTNirm
i
4223 A
rr rr,
NC Well Commaor Cenifeeation Number _1I3:Ott76R G24SiA1(F ortnaritl astvl li OR'I INER b f" Aca�
iRdINr TO ft MFTER 7rlrchN M MATERIAL
SAEDACCO Inc ft, fr. in.
Cain wq-Naarc 1b.:tId TER t ASrNG'BFt,TUBING' Ecitas'sf In da _
FROM TO DMINIETER Ttlict:NESs MATETtIAL
t Welt Constavetlon Pcomilt#: 0 A. 40 ft. 6 ia- sch 40 PVC
Iistallnpp)ik able wdl prnwirs fie.Carrnn;,Searr,tladri re,11factien eir.) ft, tl ire
3.Welt Use(check well asc)
Water8nl)Ith'Well: 1R4�a TO PtA!)i.rT R 5tAT5r7P TnTtK14)'33.5 MATERTAT.
0Agricultural 0municipal,71ablic 6o It. 40 fi 6 in. .020 SS
❑Geothcfml(Heali oli Supply) ❑Residential Water Su rL
ttgtCo ttd ppty{single)
0itldustcia.G'Calnlnercial ®Residentiat Water Supply{shaTaad) FROM TO I ASATER!]ei. EATPLACKML�1TIWMOD&AMOUNT
❑irti tign 0 ft. 34 IL Portland Trim
Non-Water Supply Well: in fit.
❑iNWri#Orin �Recasr
Injection Ellett: _
•AquiferRecharge NQroTlndnRtcritcmcdiation -14SSANIa L,PACKPt': xebte .
❑e4gtrifer-Storage a ttccmrr)' 175alinity l3arries TO._ __._ KATvtt4tt._.._.._- - - �hrt�r ac�s►tr iT Mt;7r r n _
65 ft. 37 rl. Sand 3
❑Aquifer Tcst ❑'Stomtsutar Drainage R. ft
❑xperimcntal Technology ❑Std)sid=c Contrut
�1ti:�A�RII:.LT1t1G°LDCr'(a�lta�hae7+�iiinnatsliee(s�rMci"asai �)
❑Geothermal(Closed I.oap) ❑Tracer "0111 To PESCRn'TION tcolor.bArd" 90141rncA lype.,grala rye ear''
❑Geothermal(Reath e)Coo Return) 001her(esplain under#21 Remarks) n rL
(L rt —
4.Date Weff(s)Conlpleled: 2-3-2022 WeUID#EW-62 See 6Bp s notealL
Sit,Well Location: fL ft.
Chemours IL ft.
Faeility,Owner Nonce Faeilily IDk{if applicable) ", A.
1248 Bill Hall Rd White Oak, NC 28399 Cumberland C, fa ft,
White Oak, NC, 28399 Pb)sscalAddmss_City_and Zip 3t:It laiAitt:S.,
Cumberland 65-60 is a 6 in SS sump
S cooly Parvcl tdeihlrwillon No,(PIN)
Sb.i*itude and Lc ngltadc in dcgrccstmintrtcslsecands or decimal degty= 22.Certification:
(1rwell feCtd,om L-W7utt 3R Rrdlicient)
N W Chris. Ruffer 2f3f2022
5i�aatarr of Gcnifzcd Wcfl Cantr:tchcrr Doe
6.Is(are)the w'ell(s): IOPetmanent ar oTemporary' !�•signing rhlr form,1 herein'rerrify Mar the u+rl4s)%soy{w err)c minrcred ire moorland•
lrirh 15A NCAC 01C.0100 or f SA ArCAC 02C.0200 Well COnstive wr Smadards and Aar eT
7.Is this a mltair to an exitFort;well. Efts or NNo ropy of rllzT rein%i hff h✓'evi pwrirkd fn rbr per))motor.
!f rhfs'is rs repKTir,fill eair Amr,r veff~rN Wev Mfomiarkm trot expfohl row nafure of Me
repair ardor 621 nmarla serrian ar an the bra of this form. 23.Site diagram or additional well details:
You may use die back of this page to pro%ide additional uvU site details or weli
S.Number of yells oonsintcted: 1 construction details. You may also attach additional pages if necessary_
For muMple iRWihm eN sari-krrer sVpl-wells ONLY r:frh rive mme e.Taatructfwr;o.4 ens
sabmir aae form. SUBMITTAL INST CTiONS
9.Total well depth below land surface: 65 (((,) 24a. Far All Wells Subs it this form utilhin 30 days of completion of sill
For rnuliple wrflr)isr cell rleprhs fl diffilrenr(exovvfe-30200,droll 3@ 11K►') cons(mction to the foltosins.
Ia.Static water level below top of Casing: ((l,) Division of Water Resonrres,Information Piocessinp Unit,
11 outer)etgq it 10hd a EMONg,ase"+" 1617 Mail Scmice Center,Raleigh,KC 276r1-1617
11.Borehole diameter.10 in (in.) 24b.Far Inicrtlon Weill ONLY.: in addition to sending the form to the address in
24:above. also submit a copy of this fort within�n days of completion of wall
12.Weil eomstrnetiou method: Sonic comlmetion to the follow:
0 e.as er.rotary.cable.direct Vush etc.)
Dh'islon of Water gem"vs.Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 MAR Service Center.Raleigh,SIC 276"4636
13a.Yield(g,ma) Method of test: Lic.For WaterSapely dr ini640oa We11s:
Also submit one copy of this fonn within 30 days of completion of
13b,Disinfection tvpc _ Amount: well CRnsiniction to the cpuniv health depamnent o1 the caunq,w h=
constructed.
i
Form GW-t Notib Casrlilm DcpaArnent of Eaeimmixiu and Nanunl Resources-Division of Voter ttesotrees Revised AtVM 20 t 9