GW1-2022-05128_Well Construction - GW1_20220531

I
WELL CONST RUCI`ION RECORD FucivacrntrlUsot7TTaaL1r:
T8r`s form can bc'used fffr•shi„Icoi rniiltiF9c.Wells
1.W611.6tttractor futorntation:
U.%YATER"ZONES
Chris Ruffer FRUNt' TO 13"CRrPT10N
'r3'011Cpr4caciarMarne, ft. ft,
4223 A
ft. ft.
NC WJel]Contractor Certification Nuxb& •15.OUTER CASTING Mw inutil-ca*il weI-4 OR'LiNFR lii:a t`l3eabk
FROM TU DwtsTHR .T'FtrCt*;.VES ll TERL4L-
SAEDACCO Inc ft. ft.
(cmgrur}r mC MANNER CASING OR 7l'SING f'entherm l crow—two)
FR01r TU DMIETE-R-1 THICKNESS 1 ➢rATERUL
2.NVellConstructiontTct mil t 0 ft. 8 ft, 6 u4 sch 40 PVC
J�uarr�p r,�nnt�>a�ir >sir:Ji r.cnra thv;Scut,trnrirttrrr,l ttdpa eir.)'
3.Wcgt c(checliziMl asc): s7.St,tzE EN
NN.'dtCl'$Olilyl�'��;Gti:" FROM I TU DIANI:TF`„Et SLOT$17Z TnICUNFS5 'MATFRiAr.,
QAgrku,Itural bMunieipaiM1bli"s 1Y rr: 8 ft, 6 in. .026 ss
®Geothermal(HeatinglCooiing kiply) ClResidential W-1ter Supply(single) fu fL in.
®industriaUConmicrciai ®RcsidcntialW.nW Supply(sbatrd) FRoGROUT TO MtnrRutrny I FA[PL+CE5IEVT\1-SiII0Dii,%r01I1VT.
❑lrii anion 0 ft. 2 (L Portland rTremie
Non lvataSupplyNY& rt. rt
Qhlonitorina �Ftcco�rry
injceUbtt well:
ft. it.
�IAgrriferl;rcilarge HBGiuuridssntcrRciiiediation 19.SANb1GR�tVELPAt'K(ir'• trticr�lstel
FRrISr "rtr nL+,�rF;ttrnL Frtrt�+;Gr�n:NT ut_Tttt)u
l7Aynifcr-Siort0cabdRccmvy QS;tlinilyRairicr le ft. 5 A. Sand 3
❑AgitifcrTcst QStommltcrQitina�c R. ft.
gcrimcntal'1�lgngir<r�• G]Snbsidcrrcc Colttnol
70 PR1LL1NG'LOG fallach additiaoal sheets if r eLmar i
❑GxdtelnLd(C1tlSeriLoop) ❑Tracer FRObr. To
DFSGRIP.TIU� cat3r.tmn7nca xtl'ntctih "riructal
❑GLothenual(Heatittu,'Cooling Re1um) []Other(Lx Iain under.#21 Retuarl s) ft• fL
ft. (t.
2-15-2022 EW-44
;t.DatC:�1 LlI(a)Conipletetl, 4Yc11ID# See Gap s notelLI V --
Lj
Sa,Well I.ocatinn: f4 fL
Chemours ft ft.
Facilsi},Chyrx r33aruF Ficility ID (it applicab)c) ft. A. r -C.;,c^ru=i.•tg Uri.
1248 Bill Hall Rd White Oak, NC 28399 Cumberland C, ft. I ft.
White Oak, NC, 28399 Flty'skidAdd ss.Civ.,lindZip 21.11ENIARKS
Cumberland 18-13 is a 6 in SS sump
C<tnulZ' Mill hlcrrlif=AJDn No,(Ply)
fib,1,4titinlc acid l.gngitRile in Ilegmesiminutc kioinds or decimal dcgred. 2L C'ci•tilicatiori:
tlftttill fi;;IQr tbtC I:xtflDtza•3ngtrhici~ul)
N «I Chris Ruffer• 2/15/2022
Si tursafCcnlfiedWLellCantractor Dale
6.IS(ar)lltCis'CII(5}::x81Pll7tINItC'RI Or I7Trnip0l".rrV jfy.•N nor•,efris.rrrm„J herrb•crrti s rJitrl flte n•rl sJ✓•'n'1 ft.'erx conrtnr[•frr/Lr ace tdance
s e i l .• t( 1
u'tA J5A NCAC,M,oj()o Or 1.5 NCAC 03C iT?rl(7 ltelJ Coirsrrr;char Sfarulcrr s nrrd rJrirr tr
7.,bg thts a reirlir to an C-A iting Nvellf lyes Air MNn ri+Jis..cf rfih rerrird 60;4-ra pwrith-4.1 t )f,4!'tnYll(nmer.
1trJtP,r Js,a n tntir.fiR out kv,o4 w mall[tixttsmrMoo,11r)anrtmr:at awl Vaplain Me rrariare of The
ra',wair•run3¢r421 rmiar,Ce.char or na Me bcwk of rltis•form 23.Site dingrancor additional:well details:
You may,nse.the back of this 0gc.to"p"toyide additional Avail site:detaili:or ti'ell
S.Number of*616.0 tract ed: 1 c6tistmetiori details; You itlay also attach additional pages if iiwessary_
Far rma4dc�eJr�erk�it a*€rnr�n-iiiser xr�,trii tvie'11r phGY tr3th rAe xoxlr rairstrnertar,tirar.cvm
sattNrrit arael(arra. SOBIMIITTAL iNS7'UCTIONS
9.Tofal vvell.i epth bgto*hued surface 18 (ft,) 24a. Far All Wells: Stihtnit ddr t fD"nn within 36 days of completitn of Well
Fi.eareatltt�Jrexcltx`dPsiaviJaxgv+sfftffG re�rYfrxtrrra Pr .1 aMl tRAi�•a ;ldl9a' constnictitaiwihcfolloMing::
10.Static water level helow top of easing: lD j Dig ision 0f Water R�ou rci r,infDrrnation Processing IInit,
if ssu;ee let,ed h aLUve caskgr ttxe"+" 1617 Mall Service Center,Mileigh,NC 27699-1617
1I.Burchale diameter:l0 in (;n.) 24Ei.Fnr Iulcctlarr Welly ONLY.; 1n addition to sending the form to t)te address in
24 above: also submit a Copy of this fonu within 30 days of completion of w6l
12.«'ell construction method: Sonic Lonstructiou t6iltc following:
0'e.auger.roiaiy:wblc,dimct push eta.)
Division of Water Resoutres,IIudetground Injecliirn Control Program,
FOid NVATER.SUPPLY WELLS ONLY: 1636"AAH Service Cenfer.R aleigh,NC 2'7699-1636
13a Yield(gpm) ,1letltod of tc5t 24c.For Water Supply&-inicetion Wells:
Also subinit otre copy' of.this form wilbin 30 days of completion of
13h.Disinfection#pe:. Amount: Nvcli construction to the county hcahh department-of the-couruywh=
constmctcd.
Forte GSF-L North Carolina Depaumcm or Environtnctrt and Wautaal Resources-Divi;Ion of R'alcrRMuL rem Revised August 2013