GW1-2022-05217_Well Construction - GW1_20220531

WELL CONSTRUCTION RECORD
For lr%znW Use.PNLY:
This form can be usedriiiiingle ci rnuJ60L-,wd1s,
.11 Wiffdintntt torlhkfortua'tiotl:
M IYATE,R ZONIS,
Chris Ruffer FROM
4223 A ft..
NC,Wcll Contwor CbftiWxjo4iNiinb'er 15.OUTER. NASINgq)�,milt 11ka�tll wi lEl O R LIIITR 67,acabe),
I 7FITGE„IES:i
SAEDACCO Inc
C";uiy Nowe M.-INNER CASING ORTUIIING'k-eodivr alclosed4wo)
FRONT I To DMIETER THICKNESS \L"TFRLkL
2.4eil Construction 067nit 0 R. 10 fr. 6 lno_ sch 40 PVC
lift 411-1;i11'able wellidoiliwir. 01rJ1 l ---------
I W0,1116cicircel;Wel,t iscj- — ft, It, M� J
' -1 1 —....1; -_ 11 :. MSCREEN
WAXIM Supply FROM 1 ,10 MWETKEE: ..SU)TSIZE. I"II]IM-NF-45 I MAURIAT.
0A96CUl.61 rd'1 0.NfunicipaMtbfi.c is ft.. 20 fi- _'.'026 ss
OU90ificuml(Heating/Cooling Supply). DResidential Water Supply'(sins m
ClIndustwial/Conifitcrcial Mesidmial Rider Supply'(shamd) IS.-GROUT
Elldioption 0-FROM ft.L 5 TO MATER EXPLACMIMTkIETHOD&ANIOUNT
fG Portland pour
u-NV;fer Su pltly Well:
Injection Well:,
M,romidswkr RcHi0k-ition 19.SAN D,GPILVE LVACK(if aliplieal)k)
R6
C1A4*(cr.Sto!a g-c aiA Re6viNy Psalinily B1HCi'
I . c .1 7 R. 25 fi. ISand 3
M A qiilki T0 El'sibrinwata P'j�'ainl-
P;
Q�F,x mcnitilT-ha togy, �:ntml
Pi w 'Q a
IlGeodwmial,(f lased Law)) ElTraeff
FROM To DESCRIMUNUmbr.IMPA161L%I"%nKk ty N.0441 +se.ilt.)
oCieciffiennal(IleafiqWCaoling Return) 1110flier(explain un&r 921 Retuads) ft• fl.
ft., ft
l.I#10WOWS)Cdnlpldled; 3-15-2022 _%Vill I]D#EW-3 3
E_ 9 V E_
See Pap s notegi.
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n:
ft. I'L
Chemours ft. f42-0-2-2-
FichitpOwner Marc Ficiffity IDN(i'_ —
ft. ft, Inforipm-1 mcz—ozMg uff-
1248 Bill Hall Rd White Oak, NC 28399 Cumberland C, ft, ft,
White Oak, NC, 28399 :21.REMARKS
Cumberland 20-25 is a 6in SS sump
coliftly 111�jred
2L Certification:
N w I Chris Ruffer, 3-15-2022
flan,ctO Date
6.Is(are)the ivell(�): 71Wrtuaneut or OR-imporaty
it�M 15A AVAC 02C,0100 or ISA Wk,'.01C.02100 11ell d',q;rirrtiCagi#r Sraa&ais and AjWra
7.Is thil a rieliali to an&kting NMI: qYe5- pr O'No 1W11(MIne-r.
If.JNS�Is a ITri1r,Al 0Zq r (Ta'd expfahl Me 0111rare of Me
-par r ixt Ou �23.Site dingranioradditional wietl,jetails-
You MaOise-ifie'b5c];of this Oka,6"Pro�;ide additional well site details;or�'V-611.
8.-NnmUerof Wells&ns,tracted: constmcfloil deiviirs.: You fliav also:Atlach idditiond pages'if ne essary_
Foe,tii ifi*ittkvnlAvi zIr vumviirsr swr4y,wi7�'ONLY wirli r15 e,sairar ediistrirUlan,y lima
SUBMUTA I,INSTIMITONS
9joial.will1depth ttetdwland surface5 25 2U Foe All WdIs: S61ifirit this 116" w4lb.in 30 dqys of completion of dell
Fora aMpIr ff ooiwfil(exmnpft'� constniction-to Ilic
10.Static water level Maw top of casing:; niviNidli of w2ter R' Lgau rvi*b1hrmatibnP'recessing Unit,.
'Service
If itWer'level-bi6ore Lasiag,mte 1617 NIA.' it Service Ceuta;Raleigh,ACC 2760-1,611
11.8orrholciliaincter.10 in 24b.Fnr btfailod WON ONLY. In addition to sending(fie font to ilia addtess in
246a6os,e, also sulintit a cow of d'u's1enti wi,thin 30 days of completi6fi,of Hell12.,Wit constructionmethod: Sonic "onstractiink to ilte"following.
LA rusk ctc.)
'DiAsion of Water Resdurce`s.Uftdcrground Inje, itidn tokml Vrograin,
FOR N&Y,MR SUPPLY-WELLS ONLY:' 1636 Alai]Service Cen'ler,Raleigh.NC'27609-1636
24c.For Witer Supply A4 Injection Wells:13;vViOd(gpip) M401idd of test
Also s6binit ptle' ,c6py of.flits f6itAijMthin 30 days ofcompletion of
131i-DisinfLTfil"11.4-11ef, A aunt; well consfilictian to the councy ficall'thArlihnnent of ilic county.where.
In constructed.
Ninih Camlina Mpannient of-Envirowwn and NaLum]Resources-Dildilon of Vlalcr Rel'.0=25 RevigedAugust-1011