GW1-2022-05134_Well Construction - GW1_20220531

WELL CONSTRUCTION RECORD Fe Ir1crmI Use ol+iLv:
This form caitbc used Cm single at Intiltip}c sieils
1.�rVc1I.Contt:ictar7nforulation:
14.WATER ZONES
Chris Ruffer FROM: 10. opl-I'RIP11O
S1'tllCotyttac�ryrN'amt ft, ft.
4223 A It: ft.
NC Well(76noacror Certification NuttEei S.OUTER CASING(fnr muhi-cased wins)OR LINER f if.a i ilkable)
FROM TO pm,11ETER 'nilc iE55 hlATERIAL
SAEDACCO Inc ftt. ft. c
ftiri iany Nanic M INNERCASiNG OR 7 LiBING i'eotherinal claged-loti i'
FROM 70 QLOIETER. I TIIICt+ZiiEss hIATERLU
21 Well611,5tltietinn ocrullii;: 0 W 85 it, i sch 40 PVC
lrirkllrlgilienhJe vn4fperrttJt*ffx.Cnuntn,,Shoo,113rionce,Trye:gc.4r1c:J Ye:, ft. ha
3.Welt.U c(chrcic:wal nsc7: 17.Sf'REEN
WaterSupptyWell: FRONT. TO or.+NtFTER SLOT517): 711t1N(eFI�S`' MAT�i ML
❑AgTk Ittuld 11161unicipraVALlilic 95 ft, 85 fl. i in• '.Old sch 46 rvd
l26eoihennal fficidngfCooliog Supply). ❑Residential Water Supply(single) fi. fL-
Dlndusnial/Conii iterciA DResidential Water Supply,,(shared) FROM M -1 '
FR 70, NTATERt,1L I ENfPt;,ICEhTEVThIEi110U C,lhIO[IN1'
❑Idi'Rtion 0 ft. 81 f4 Portland Tremie
Non Water Supiily Weft:
MmanilorinG plteco;OcTy ft._ ft
h1jeetlon Well: ft (L
DAgmfcr Rcchar,-e ®Groinidssatcr Rcntcdiation 19.SAN WGRAVICL PAC ti of u i iih:ab>res
. , �.. .. '. .'. .. � �FRIlN1: TO _- NfA'tl;Eit+1t, hNl Pta\C.F:U6_\7\fFTNgtI
17Agrirfcr Stoiage and Rcco Irly I75afinity>3itrricP
95 ft. 83 A, Sand• 3
QAtluiferTeit ❑Siorum-alciDriinagc ft. it.
171 aq?otimo(7l T1z,-hnriCo(n ❑$Ithsiit.ncc Cordllrl `,o,DRILLING G LOG duuach additiauul Stieeti if rercessnry)
❑Geotltennal(ClosedLoop) ❑Tracer FRONT TO [iFtiCWPTIOrfeaknharArictt.xdd'nMfi .»tiiivanr.)
❑GLothenilal Return) ❑Outer(explain under,421 Retnatlts) f t. (i
ft. i4
#.1)atc:�i'ell(s)fortipletcrt;_3-10-2 a 22 Well7Dft ow-31
See Gap s noteS.4 1
-+ 5
5a4;Well L,matinu: ft. fL
Chemours ft;, i4
Fsaclitp,?Ow�ncrNam Ficli y IM(if applicablc) ft.- ft. F)Ttic,=1Pr,�^ "+ URii
n•£�1
1248 Bill Hall Rd White Oak, NC 28399 Cumberland C,
White Oak, NC, 28399 Piivs`xa1'Addc`skCjv.,IindZip 2t:REALA1tk3
Cumberland
Coiinb° NmCl ht,3011=01unNo.,(PIN)
:fib.Lit
titude and Longttwk in degtreslminutrs?seconds or decimal degrees:
22.Certification:
(fi4llnodrtsia ltl+7iat>;is.sum kni) /''+ �{
N �' Ch�ris,..Ruffer 3-10-2022
Siemtnr of Ccrtificil SVcfl Coniraofa}" date
6.is(are.)fhL'wellO: 'SlPCtiniltlenl or i7TcmlW rar}'. By r'gnrhg,it k.fbrm;1 hereby certify d at the irrllfs)P.mts(}rent)cuiStntezed iu acconlanre
iiirh 15A NCrtC 02C.9106i or I Set N6C.02k.02010 Well 6orritrzictl0n Siandards ttid rhar a
7:164hi_r a rcpairto an t: -sting lolelk oyes .nr MNo cyi f rlidr rrei alirslnrai`raaart&-il i�.Wr iirti motor,
ljariic t,ra rr�rlr,till anarRri.uw iicl!ie*aartaurrlJardrtfrarawarlon trirf et{�lalii day norure r;f rlii
ji.wir and;921 iivaiarRs acrlcdon or nv trio lJ7Stk f dTin foruL 23.Site dial runt pr additional well detaMs:
You-FriaY use ilse Uock'of this pa(e.io.gioc'id additional i ell site detaiis;or riill
8.Number of Wells co,ustmewd: 1 consftuction details. Yt u,ni4v aiw attach additional pages if trL essS sty.
Fur iitii.hir#e nA i-iiu-ir jaira{ntylr'lts ONLY ndrh the samr
.+" CJlPStldtal10J1,L`Jir t1 1?
"inane ir% S 1 illffTTA 1,WST T .TfONS
2.Tptwlwcll dcpfh below unit surfncin 95 ((t) 2aa Ftii All �trcfls:."Gnhtieit t is fdrixi within'36 days ofconrpfction of yVj ll
r�rarcrikl�iritfPxt3tirPtt<itu tt irraNiFx�rr,'i)Pr3+e�:�tk7"trrrrla itk7) constnrctlon.toilidfolloistng,
l(1,Statio water loser€)crow fop of cnsiu t (pt,) Uivisidu of Wzter.1160urre4,Informntion Prdeesssinrg Unit,
if iru.'ia lePrl'ir s&ui'r c�asittS:lice"�" 1617 Mail Service Cienter;,R lci�it,,;•1C 27699-1617
It.Borehole dia)netcr,6 OLL) tab.For fn[mtlon ALAR ONLY: in addition to sending the fomi to the addr-esss in
24 above, also submit a copy of tliis.fanti irithin 30 days of completion.of uell
12.Well coustruetiowniethod' Auger eonstniction 16 ih�fulloi4ine''
(Lo.aii��er,ro�aq,cable:dirrct push eta.)
Division of Water Resourc si Underground Injeeiion Conwil Program,
FOR NVATER SUPPLY NVELLS ONLY: 1636 Afufi Seri'ice Center,Raleigh,;ETC 27699-1636
13a,Vidd ftm) Alctltad of ttxt: 24a For Water Supply&lnjeetton NVeils:
in 30
• � l p y n ttoR of
13li.Li?infectinuty Amount: c omtnrcda to the county hcaith dec nmctitor the courhlhc rc
colistnutcd. I
Pm tin Gtir-1• Noah Carolina Depattment of Emitotunctii•aad�]atursl Resow-ces-Div islon of iffater RE3atra s Revised August`V13
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