GW1-2022-03219_Well Construction - GW1_20220311

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WELL CONSTRUCTION RECORD For Entemal Use ONLY:
Thy farm can be used for single or mtltipk veils
' 1.Well Contractor Information:
14.;A_Il"i81z;ZONf.fi.
Chris Ruffer t!ROht TU ptcC(Rtt'tt1lON
Well Contractor Name
4223 A ft. ft
NC -dl Cordractot Ccnifiwioo Nnmbcr ]S.'Ot!IEft:: e1SING'ToreGuMl a�eil iisA OR I IN7WR iffi''tkaL
FROM TO DIAMETER THICKNESS MATERIAL
SAEDACCO Inc IL (L in•
(nsryrml 1Vae� 7dLMER'C I GOR TUH'lE)lG eoyt stet d lar
FROM TO DL1.SiETER THICKNESS MATE'RTAL
2.Well Construction Permit a*: 0 Tt. 40 rt, 6 6L sch 40 PVC
List uflapplicnble well o nits fix.County-Vate.,Vnrimrcr,fifardoq rsr.) tL tL ie
3.Well Use(chock:well ase): Iy&G`1tl1 N m a ,
`F`aterSuppW Welk FROM TO ptAAtY,rSkI STATSIZK I THIMM'S I MAT'RRTAT,
OAgricaltural omunicipalrmlic 60 It. 40 ft. 6 .620 SS
®Geothermal(ReatinglCooling Supply) ❑Residential Water Supply{stagle) rL R is
❑IndustriallCtrmmcIciai 011esiden0al Water Sttpph•(slxued) e:'CRo[Fl
FROM TO MATKRUL Et1TPUCUALNT METHOD a AMOUNT
❑Frei _tinn 0 rL 34 (L Portland Trim
Noll-Water Supply Well: t4
❑lwlonitorin 10Hcco►
- rt
Injectlon Weil: ft.
0Agrrifcr Recharge QbGroundwatcr Remcdiation t9_SAN:bJGFlAVE1:deACI:'elf;; t' filp}
now-.-_ TO — NATISUAT..._.__ ►ntpt a. r�xlrttfiltott -
❑Aquifcr-Storage and Recovery ❑$alinity Darricr 65 Tt. 37 ft Sand 3
❑A(luifct-Test ❑SIonrm s or Drainage R. ft
❑EapcTimcntttl Tochnotogy ❑Srtbsidcace Conamt
2tt:DhiC�NCr IAG'(ai is�ch'advllfiana't ltieets�f iicctasa�•
❑Geotltermai(Closed Loop) ❑Tracer r'ROM TO mescRtrrrox otlrr.t,ardnrst sn4tnca ei9R c1r
❑Geothermal(Ileatit glCaoli Return) ❑Other(explain under#21 Remarks) (L rL
ft. fL
4.Date Well(A)Completed: 2-2-2022 W eU ID#EW-58
See 6Rp s note4i.,
Sa.Well Locathm: fL ft
Chemours ft. ft. �02�
FacilkANA ner Name Facility 1Dk(if applicable)
R. It.
1248 Bill Hall Rd White Oak, NC 28399 Cumberland C, Tr, ft
White Oak, NC, 28399 Fhysica!Aifd�ss Ciq.:vrdZip � RKk1Ax :
Cumberland 65-60 is a 6 in SS sump
County Parcel Walirr.MonNo,(PIN)
5b.Latitude And Longitude in degmvsMdnutoheconds or decimal dcgn=. 22.Certification:
(ifwell t'Kld,cute tAlocg.It WfSckta)
Chris.Ruffer 2/3/2022
Sig_n ai�afCcnifiwd Well Cenuactor� Date
6.IS(are)the rt'ell(s): mPermanerrt Or nTemporary &-signing Mir,ferrm,I Arrebh•eerfi#thru the v41(sl hwx in-ere)wminfrted iA mrarrlanrr
a rh 164 AfCAC.02C.010n or I5A AfCAC 112C,0200 We11 CanstroCrirur Stdntfarda coin rlwrr er
7.Is this a repair to an Busting well: oVec ter KNo ropy of rflir reepni h era kevj nrmti k t to,tt a nrll mmrr,
lFAis is a repair,/all4mr bw wi well eminred"ittforwurrerm mud explabi rbe tarrrare rf fit
repair wder021 reotrerkv srr ime ar rm the ba.•h of this•formf. 23.Site diagram or additional well details:
You nW use tlie back of this page to pro%ride additional well site details or well
&.Humber of welhs consirrtcted: 1 caonsinlction details. You may also attach add;tiaual pages if necessary
For,mwldpfe It fe rkm err nw vorer FJWy ivells 0NLV h'Irh the mme MRsgru l xr,,wow cow
sn$rnirone form. s 113A11TTA .INCT TCTIONC
9.Total well depth below land surface: 65 (D,) 24a. For All Wells: Subndt this fowr vdihin 30 days of compaction of well
For Atulrlpir wells lisr rtflydeprha if dr#4,gent(e•.oolpfe-3@2INt'amd 2011M"r'i construction to the f4ov&ig:
10.Statie water leVel below top of casitrg: (p,) Division of Water Rea u ree f,Infiordnatioa Ptacessintg Unit,
If kwuee level is 4brlue ewaslwg,wse"+ 1611 Alan Semice Center,Rrlei)r,NC 276"4617
1
11.$orehple diametm 10 in (in,) 24b.En jqjMflgg w'Fns ONLY: In addition to sending the form to the address in
24a abo►'e. also submit a copy of this form within 30 days of completion of well
12,Well construction method. Sonic construction to tine following:
(i.e.auger.rotary.cable direct gash.etc.)
Dh•ision of Water ResouFees,Underground Injection.Control Program.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Serwilcc Center,Raleigh,XC 276"4636
13A 1'idd(itlrm) Mettler!of test 24c.For Water Sappl &106f;inn Wells:
Also submit one cop} of this fOnll within 30 days of completion of
13h.Disinfietian type: _. Amount: well construction to the county health department of the county twhm
constructed.
Fonn OW-t Noah Camlina Elclionmcnt of Enviromncru and Nnw%il Resources-Division of 1Vat r Resources Revised August 24)13