GW1-2022-05190_Well Construction - GW1_20220531

WELL CONSTRUCTION RECORD >nrla�.r,aalus.cINI :
Tftfs form can be used for single of multiple wells
].\VclCGiuti:ictorLiftrrntatiou:
m.AY11TEx,ZONES
Chris Ruffer FRUN1. YO uF_Sr nrPTtUY
WelF Cnramc6arN;rmc R, ft,
i
4223 A
NC.Well(76m acfarC'cnifdAiaoXtuber 15.OUTER CASING(for mult}-casrd well-)OR LiNER lii s i ficaAkl
FRONT I TO, DLtx1IE.TER THICKNESS, j NTATERTAL
SAEDACCO Inc ft., ft is
4{iv4rurg':N.rn�. 16.INNER CASING ORTUBING' +�IGermalelatedI�xa't
FROM 1.70 1 10M E7ER TH1c,"ESS INT,I7TRTAi
2,W01 Constrxiction Pcjmflii#: 0 ft. 58 ft. 1 'ua• Sch 40 PVC
list rrtl a�ilicable v rtltnaiaraits li:r..Caunry;,SrxrJr ,Yariarrcr,Irxtieeb rtc;)
rt.. 9M,
3.Wcll-.Use(checkwell use): r7-SCREEN
\;'atorSnpplgLVcll:; FROM- I I0 I nIANIF.TER I SLOTS ME 711tC'KNfN-9 I MATrRIAL
L'1AgTicultil[ai CI141tiniclpaUT'tibllc 58 ff: 68 ft. 1 in, 010 Sch 40 PVC
i36cothennal(lleatinglCoolin0 Sttpply): 011esidential IK to Supply(sing1d)
®hidlstrillfionmtercial Mesiden@alNx,'atcr Supply(sllamd) 18.•FRO ' ' 70, 'MATERIAL I ENIPGACENIE-NTMETHODSAMOUNT
❑Irri ution 0 ft.' 52 rt. Portland (Tremei
Non AYater Supply We":
l7hlonitoring. 49R�otrTy
Iu3cetlrm\vctt: rt.- rt;.
ClAgnrfcrRcciTarge 06ouTidii-niaRciucdiation 19.SANWGPLILVEL PACK fir ai0I-abed
THOM, 10' NiA,W11 ru, (srPt At F,yrr�rxn:TniTn
17AqurfcrSt6i3gt 1i-JR covcV Q811.irhity131hicr 55 'ft.. 6e ft. Sand 2
❑AguifcrTcst ❑5torrovoatcr f)jarn;tgc
17l.xpGriritcnfal 7Ll1 indlogy bSRb5idcnce Cathlrol
20.DRILLiNGLOG(allied addiii6tval sheets if necessary]
OCr`athennal(Cl)sed Loop) ❑Tracer FRONT .70 1DESCIETFTIO\ calir.h:trxrti��.s+aTh+tcti t td Le dr l
❑Geattenttal(Fleatir�t CnolIga Rea nl) ❑Other(e cplaiu under 92tRemarks) ty, it,
.DatC*\4(i)f-bn1p;e1cd: 3-31-2022 _WellJD#OW-42
See Gpp s noted4
\Y�ii larcatiou. it. ftMAY 3 1n
20
Chemours r4 i4
�-
F�cdit}•atitlyracrNarttc Eaci1B+•1Dn(3eapplicatajej
1248 Bill Hall Rd White Oak, NC 28399 Cumberland C,
White Oak, NC, 28399 Fltysid.addicsc GiiS-iandZip 31.REIIL�AKS
Cumberland
CxTnnly 1?Jtrr:el ldealirrr;ttion No,(1"I14)
ih.I atitutic and I,nng fndc in.¢cgmcscs rnint'rt�ascctinds or decimal ogees. 22.Certification:.
(IfirclDBctil,�Wi�i.Ti,+7a��rutlic.iktA)� �-y {�
N \\' C,h�rit,- Ruffer 3-31-2022
Sigrutittr of Certified Well Coutractof Date
�1:1s(urc)tire-�tell(s)::�PerrriaucRt or. i7Temporary. -
iYy rrgtling ilrir fuam„1 lrerelix•s'ertife 65ut:dax ll'ell(.YJ N,TlY{41'C/i!}COT15'1NLl!!1 J(r-RC4`OY(ilR1Ce
riiria 15A NCAC 02C,010t7 or 15A NCAC biC.0200-Well roaratrncilar Standards sad char a
7:1sIbL4 t rei'mieto att i xi.ttingwelk 13Y tor MN�r cry�rbjrlidfrarxirrdlir3LLTit'rarnridrd initr Tirdlmv;rcr:
({al ls'Ix a retsrlr;�alt,�r ra7aw ltett CYTr.Iy!/Kwclo brfotrarrr:oa(Vul e,xpltaiat the itoraare of rlte
iYvcirramttrl?.Tt snwurds:ti leurl arttn rtrc&7i!"Idd.,prar. 23.Site dlllgrat Or additional well details:
You Nay use,ae bock-'of this{To&e 0 provide additional well site,details�or welt
8.Number of Wells constructed: 1 cobstraction"detaks: You:itlar als~o:attach Aiitioilal Pages if axes sary.-
Fear ma�ladc�fe hSi�tiili�i car rant-ntiarer aarlaln{i rcelts Pt�'4}'a tree rlic.urnre tnarsYruetiar,}c}:t.arn
�x$,viet drue,tFamt: SUBtIiITTA L INSTUCT'IONS
9.Toialwclldepth below-landsurfaCe: 68 (ft j 24a. Fri.-All Yells: Silhtidt this form ttithin 3o days'of contpleiion of Bell
Fier maMlrlFta ii elts'lrcr tzPJ�" r�rt'itrrrit isxtrr{t 1r 5 :tlil'arxF3+E�ftk1) con5tnicti+iri to tk follAttiag"
10.Static tsater level]plow top of casinw. (B,) Division of Water R6Iou rcel,Information Prncr ssin�g Unit,,
Ifttulvt.level&Rhraku edISIftw,ate"4" l6i7'AfaiE Service Center,Raleigh,NC'27'66 4617
11.Borehole diamctci:6 in :(in) 24b.En_r Titjatlag Wclly ONLY. ifn addition to sending the foml to the address in
2#d,bone. also submit a copy of t➢iis.foirn Within„36 da}�s"of conl)ileaon,of tcdll
12:Wr ll'rnTrsfrlletion method: Sonic c'nflstn etiou collie folloV01.12:
{Gc.pugec.ratur}.c.uhic:.diieci past.ctc.)
Division of Water Resourecs.Undc1'ground hilecilon Control 1Priigram,
FOR WATER SUPPLY NVELLS ONLY: 1636 Rfall Service Ccaler.Raleigh,NC 27699.1636
13a 1 acid m) 71'Ictiiod of test• 23c.-For Water Srippl�.&Injection Wells:
Also subinit one cop), of.this form tFithitl 30'dnysofcoinoletianof
13b.Disinfection h- e Amount well cowitnictibn to the county licalth deparimcni iif the,coiiidv twh`m,
P`•
constmctcd.
Fora.GW4 Nonh Carolina Ucp'snrtacnt of Ern+irottaxnt arad Nataral Resources Dividon of 1FatcrRewLrCm Revised August-{fl3