GW1--05362_Well Construction - GW1_20240909

WELL CONSTRUCTION RECORD P«!menial Use ONLY:
The form can be used for single or multiple wells
I.Well Contractor Information:
14:WAlltalll
Chris Ruffer row to DFSfRtPttON
Well 1'e11010or Name ft. U,
f6 fl
4223 A
NC Well Contractor Ccrils Alan Number i IS.OUTER CASING(far multi-casedwc�OR LINER oil fixable)
r*ON To ' DI;MrTTR Tntk;'pis lavrip Si
SAEDACCO ft. 0. ra.
(onq:,ns \.ou. IC ININilt CASING OR TIRING tigatller•nal dosed-loot)
FROM 1 10 DIAMfTFR FOR ANQSS MALL MM. '
2.Well('nnu:victinn Permit#: 0 n, 15 ft. 1 Ie. SCH-40 PVC
liar of a ,lftable Wr11 prrnuta ri.r.County.Skala,Variance.Ilefhdt rlr.! n, jft. in.
3.Well t'ae(check well noel: a
17.SCREEN
Water Supply Well: nOM TO ORM►TER SCOT sin ; tnt(klut%s M+irAtat.
LIAgrwultural OMunicipal/Public 15 R. 20 R 1 ia, �010 ,SCE-40 - PVC
OGeothemtal(Heating,Cooling Supply) OResidential Water Supply isingle) R. R IN.
❑IndustrialComntercial °Residential Water SupphIstriad) IRG1OIN
FROM TO St STERLAI. EMPLACEMENT 14E11100 A AMOUNT
❑ligation n. it.
Non-Water Supple Well: n. n.
ODhlotutonng ❑Rccotrry .—
Injection Well: n. n.
LI Aquifer Recharge ❑Groundwater Rentcdiation It SAND/GRAVEL PACK Of applicable)
MOM TO SI atE.R10. E.MPt.a(TAIT TMrtnon
❑Aquifer Storage and Recovery ❑Salinity Hamer r. rt•
❑Aquifer Test ❑Slomm:acr Drainage ft. ft,
--
❑FquenmerRal tcthuRilog4 ❑Sahsiikn c('nrrml It DRILLING LOG teasel addiunnal shell,if accyr+an I
❑Geothemtal(ClosedLoop, ❑Tracer now to Dr.(RIP IIIt't,r,.`r,hu-dues... m...4 elpessanin arc,(ic.t
❑Geothermal(Heaung.Cooling Return)
❑Other(explain under _1 kenurla) R R
R. R.
4.Date Well(sl Completed:
o-13 2024 Well1DpSDC-5 ja, See Gee'ra Notes r a u `y,� "3
Si.Nell Location: R. h. SEP ® Q q/ �jcl
Catsburg Country Store ft. eft. C ✓ ?02.1
i„t1,,,1r`.;nc Facility-IDk1(if applicabk) rt — n, irate',*.t j- ;i..- Y
3a ^,g l:acil
1110 Old Oxford Rd., Durham, NC, 27704 n ft. - a�kr�nii
Physical Address Cie.and Zip l 21.REAI,4RKS
Durham Grab groundwater sample via 1" temp well
1,,.r r. Parcel klcuidtcatior,N.o i PIN 1
Sh.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(It well laid.ant La:Iong us sufficient)
iS W Chris Ruffer 8/16/2024
Si,:rutus of Courted Well Contractor Dare
%.I+Iaret the ot-111+1: Permanent ur RTempuran 0., signing kids funk 1 herein certify that the 1141(.0 cur fwt art courmevesd in accordance'
War 15.4 NCAC 02C.0100 ar 15A NCAC 02C.0200 Well Construction Sroakudt and rhak a
7.I.this a repair to an esistieg well: Yea or DO No trot of Mir moron,hat berm provided to doe surf turner.
1f aSia as a?.pair,fill anal Rn..Wu Writ r(WU(PIA Naar kafonnera.n owl rrpkaoi tM auarnrr of(SW
repair under 021 remarks ar cum or ran the bait of Ibis form. 23.Site diagram or additional well details:
1 t:-u may use the back of this page to prosaic additional well site details or well
8.Number of wells constructed: 1 cottsituclion details. You may also attach additional pages if necessary.
For m..• , , vi-tinter urpph ucr'tls ONLY,ruin(hr WM,Clmsfrvr aR t..a"SR
sabrnrr.,m �. . SIIBMITTAI INSTLICTIONS
9.Total well depth below laud surface: 20 (R,) 24a. Fur All Wells: Saint this fonti wrthm 10 days of completion of well
For mabipk well;list all rtrprhs ifdifirrnl icrainpk-t!z?rW and 2i?10.1) construction to the following:
DR.Stalk water level below lap of casing: (f•) Division of Water Resources,Information Processing l nit.
limner lrvrl et aMnr setae-OW..+" 1617 Mail Nervier('cater,Raleigh,NC 27699-1617
It.Borebulc diameter:6" (ht.) 24b.Fur inaction Weill ONLY: hi addition to sending the form to the address in
24aabone. also submit a copy of this form within i0 data of completion of well
12.Well emblem-tam method; Sonic wrlstnictiun tot lie following.
tic.auger.reran.cable.direct push.ele.t
Division of Water Resource.,Underground injection Control Program.
FOR WATER SUPPLY WELLS ONLY: Ind%Mail See ire Center.,Raleigh.N( 27199.IIJ6
I3a Yi(id 1Rpnu) Method attest: 24e.For slater Suppy 1.Injection Wells:
Also submit one cop]. of this loon a iihm tat days of cottipletiuu of
IJb.Disinfection ty pe: Amount: well construction to the counts health department of the county where
eonrstmcicd
Form CW-I \enh Caroluia Dqumntnt of Eery usiumu and Natural Refnieccs-Div eau of Wale!Resources Nes cud August 1,01 1