GW1--05363_Well Construction - GW1_20240909

WELL CONSTRUCTION RECORD For let:null Use ONLY:
The form can be used Is single or multiple„ells
I.Well Contractor Information:
II.WATER ZONES
Chris Ruffer rp(I%t ! n) J tWS('RlPtloN
Well Corrtricwx Hank ft, j O.
4223 A ft. fl.
i
N( Well Coramctor C:mi(aanion NumberIS,OUTER CASING tier awM i O i-casrd%ObR LINK(Y apkWaikiki _
nest I to I Dt‘MttrIt THI('K'r.i I SISTTNISI
SAEDACCO h. n, 11 Si. III
compass Namk 1d.INNER CASING OR TIRING(jrodleraal c cued
PROM TO DIA.METEN TrllC'KNESS MATT NI\L
2.Well Coastrpetion Prrmit 8: 0 R. 15 ft. 1 in. SCH-40 PVC
Lia all uppli.nbfr w ell pt.-mats i 1-r.County..Vow.tiariam-r.LTiecriat enc.)
ft. fi. in.
3.Well 17we(cheek well use): -.
tic S('REEN
Water Supply Well: - rims' TO DRAM►Tra SLOT SITE TNI()\I.) M\rTRIAL.
❑Agrwultutal °Municipal:Ptlblic 15 R. 20 ft. 1 is 010 SCH-40 PVC
DGeothennal(HeatingrCooling Supply) °Residential Water Supply(single! rt. ft IL
Olndustriat'Contntereial °Residemwl Water Supply(shared i s (,R°t T i , .. _ MATERIAL [MRACEMENT SIE TNOD A IN(?(STD
❑kngatron I. ft.
Non-Water Supply Well: —.
n n
IDMoamnng ❑Recovery _,
Injection Well: n. II.
CIAgInfo.Recharge ❑Groundwrater Reniediatim I sAND;t.It1VELPACK r Rtalhll/
i-is/NI ' lit MATERIAI. Elan AI-TAUNT Mrtnon
❑Aquifer Storage anti Rttm'en ClSalinip Ramer It R. —
❑Aquifer Test DStomtwater Drainage
H. h.
❑Evpenmental TIN hnoloHn ❑Subsidence Control 7ii iiumIIN.c.!i)G(MOO ItdlYUaad Sheds if overman t
OGeolhemtal(Closed Loopi ❑Tracer rwomt tic DESCRIPTION Ira1., hnennen.,wiknMl,n pr.yaw r.ent.1
°Geothermal(Heating?Cooling Return ❑(]tiler(explain under a21 Reutatisi R- ft
R ` ft.
4.Date Well(s)Compkied: 8-13-2024 N cdt in.SDC-8
n, See Gismp's Notes ^ +�
5a.Well Location: ft. ft. L. I ' D
Catsburg Country Store R ft, S E P 0 9 2024
FaeUiyi'oacr Name Faclity W#(ifapplicabkt R. ft.
J
1110 Old Oxford Rd., Durham, NC, 27704 R. ft — .f,.x A.i..f- , :ow:: m(3
Plnsteal Address.Ces.and Zip 21.REMARKS D r't"1""
Durham I Grab groundwater sample via 1" temp well
i
i
('aatrh. Parcel tdcm,f e:iiin,.N.. I Ph',
5h.Latitude and Longitude in dctp'ecsiminutes,Seennds or decimal degrees: 22.CenlRcatira:
irf well/kid ono l:w.long is red I'clean 1
I, W Chris Ruffer 8/16/2024
Signature of Certified Well Contractor Drrc
6.Is(are)the wellls): DPennanrnt or >OTeatparan M aigrung rhu loin,.I hereby certif%that the wr1((so MU turret rtvwrtrveled HT acrordmrcr
%TM 154 NCAC 02C.0100 or 154 NCAC(12C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: :Yet or NINO r.pr M'rfic rrrnnl hat Ni.'..pr,,tral d to the torn owner.
if shta is it repair,fitl on known weft"Noma roe,anfura„rive,and a spite',;5,naraee of rhr
repair wader o21 remarks Archon or on the bait of Mir form. 23.Site diagram or additional w ell details:
1'oi may use the back of this page to provide additional well site details or well
8.Number of wells atRstsmeted: 1 caluttuction details. You may also attach additional pages if ttecessan
For mwhapk infeerloli or son-welter suppli wells ONLY..it'.OW came roasrrveri.a, serer raw
swbmir air fcwr, SU!BMITTAl.INSTUCTIONS
1,Total well depth below land surface: 20 (feat 24a. For AU W'dls: Submit this font within RI days of completion of well
For.N,hlpk writs Ii0 aft&a to ifdrgaretu lesample-30200'and 2*1011) construction to the following
le.Static water level below tap of casing: (ft.) Division of Water Resources,Information Processing I nit.
If woke lrsr!n.rho,r,aswg.an. . 1617 Mail Smicr('cater,Raleigh,NC 2 7699-16 1 7
I i.Borehole diameter:6" (in.) 24b.For Injection Wells ONLY: hi addition to sending the fotnl to the address in
24a above. also submit a copy of this form within'k0 days of completion of well
12.Well construction method: Sonic :otistnuttwu to the following.
ii c.auger.roan,cable.clued push.etc.)
Dhision of Water Resources,U nderg d Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Set ice Center.Raleigh,NC 27694i-1636
13a.Yield(gl,ni) �et
21c.For WaterSupph Al.Injection Welk:
-"- Also submit one cops of this form within to dm s of completion of
13b.Disinfection ri pc Amount construction constction to the count} health deportment of the county where
constricted
Fenn GW-t 'sunk Caiollma t)gsuimcni of Em,mmtkiu and Natural Resources-Dhaioo of Waler Resoucm RCN wed kigtat 24,1