GW1-2022-05412_Well Construction - GW1_20220311

FELL CONSTRUCTION RECORD For bwnml Use ONLY:This form can be used for single or multiple wells o�o([F i e I d.I D #])
1.Well Contra.►tor Informatton:
Chris Ruffer WROsi pFgCreri�IrOs
W01ContractorNamc ft. ft.
4223 A ft. ft
NCMlellCordmctor Certification Nuniacr :y3:OUTERCISiNti: +�rmtihlrasedt►x8x'ai{I:l if:a"ika� `
FRONT TO ntatiY M TBIMMESS AIAT6tiiAL
SAEDACCO Inc f4 fL te.
('n,np:ui?Manic 7d�Q�ll�]FR"GASITiC'OIt;TU61N'G• f6e�sielutedaiiti
FRO7nf TO DG1iETER TBiCXNES4 MATEWAL
Wellonstt7rCtton PCtTnit t:: 0 ft. 17 ft 6 sch 40 PVC
fist arflaptifircahlr.x-clt prmririr fir.t"rurnty.Slate,trnrirarrc-r,Trll'e,:tYtx;rh:.l
ft. fi.
3.Well Use 00cli well 0SC):
Water Soppl Wc)1: Fltorl TO 0MIM;TMR I SLATSIZZ TNrMM I MATRR1At,
DAgricultural DMunicipat-Public 27 ft, 17 ft, 6 in 020 SS
❑Gcolhernial(Heaii Cooli Supply) ❑Residential Water SnRA S{single) ft' R in
®lndustttaU'Conttnercial ®Residential Water Su ppt)Istnttrd) FROM TO MATERML I EMMAC'EMENT)lU IiOD B A74OUNT
❑im lion 0 ft. 11 fL Portland Tremie
Nan.Rrater5upplyWell: � r�
oldwtorin Wliscove '
eeiloit Welt: M rL
UAquifer Recharge MGFm nd4-alcr Reurc4imion :.1y SAND1,'RAIIEL 1'ACi+ ,f:
PtiOi►t- __ _tliA URLAT.- _ l ttiw nor F�l ltit T wOb._.
D.Agnifer Stontgc and RCcovcry Milinii31 Ranier 32 ft. 14 ft. Sand 3
❑AgoifcrTest Ostomm-3tcr0minatc ft. ft.
❑Experimcntal Technology ❑SUbsidcocc Control
2fr DRIL�NCrI;DCr(alsieli a�iliiionai611eeJs3faccessa
OGtotitertttal(Closed Loop) ❑Tracer FROM 70 pkSCRiPTtO�oQkr.A�aMnet+rniRmcA rl rktarlai
❑C"Illettnal(Fteatit u,C otine Rental) 00diff(ex0aill under 921 Remaft) ft, ti
FL fL
4.Date Well(OCompleted: 2-11-2022 `jreUlD#LEW-46 See GBp s noteSL
Sa.%licit Location: M ft.
Chemours ft. it,
Factl4.AN©cr Name Facility lDk(if applicable)
Ft, to MAR 1 2022
1248 Bill Hall Rd White Oak, NC 28399 Cumberland C,
ft. rt,
White Oak, NC, 28399 PlryiicalAddmss.City.rmi!Zip :.41FRMAIMS,
Cumberland 32-27 is a 6 in SS sump
(:gutty Nrcel Irk oliFlcaUpm No,(PIN)
Sh.i atitude and 1,onf(tude in ftmes4nioutalsetonds or decimal degrees: 22.Certification:
(II well kid,core h0ofig..is Srdlicietit)
i W _ Chris Ru_ffer 2/11/2022
Signatory el"Cenifrod Wctl Cotimmot� Dale
6.IS(are)the well(!t)t xPermanent or 07remporary &*nin,g this fwm,l herdn•certdly rhar the ivell(.r)huy f mrraJ mmanrered im mrar&mvv
wash 154 NCAC 02C.111M ar 1 TA JVCAC 02C.(l M Well Conatrrordym Standardia mid char 4r
7.Is this a reliairto an existing reed: !7V s or UENo copy nfthtr reeord"Ja en pmri'rlr'd ra Ow not1 t twer,
lf;641r0 repd1r,fill.xarknraiwa Wellemurrarr&V trr10nMTk4i andraplaJat rlae ararare of rile
repair w der rt31 remarkv xretican or cm rile box•&of this•form. 23.Site diagram or additional well details:
You may use die back of this page to proAlide additional avil site details or welt
8.number of melts constructed: 1 construction details. You may also attach additional pages if necessary.
Fear mmalriple Joferrltn err nevi- parer ruTpAv wells llNLl'n•Uh rho some constrar".ym can
st4vii it am form. SC1BMUTA .INST T TIONS
9.Total wetl depth below land surface 32 (ft.) 24a. For Att Wells: Submit this.form within 30 days of oompkilicn of well
For nwhipfe wells lrsr all deprbr if dlpi rew 0,ex4nwp1e-.te,;lV0'and 20llk consinration to the foltowing-.
10.Static hater level below top of easing: Ito,j Divisida of Water ftesourctr,Inforniation Mcessing Unit,
f/»voter level is atrotT a�strag,am^+" 1611 Mail Sm ioc tenter,Raleigh,NC 2 7699-16 17
11.Socebolc dinarctcr;to in (in.) 24b. t 'ukW!Ra AdLg9NLY: in addition to sending the form to the address in
24a abotie. also submit a copy of this form within "days of completion of%veil
12.Well construction method: Sonic Construction to the following:
(i.e.aupm rotary,cable,di3m push etc.!
DhIslon of Water Resources,Underground injectlon Control Program,
FOR WATER SUPPLY A`ELLS ONLY: 1636 Mail Service Center.Raleigh,NC 27699.1636
13a it`idd(ftpm) Method of test Z'�For Water Sapely&ink0ion��'Cllg;
Also submit one copy of dvisl feral within 30 days of completion of
13b.DisinfLetion h construction
Tc _. _.. Amount: n-cil to the counly- health depadmrnt of the count),whore
constrtacied.
Forin G W-t Forth Carolina fk uaffirnt of Envirwmacm tad Nnrrirtl Resources—Divislon of WAlcr RdSOUtM Revisal August 14013