GW1-2022-05157_Well Construction - GW1_20220531

WELL CONSTRUCTION RECORD Far,trJ�rnnitrsrpN�Y:
This form can be used for singic of multipk isctls;
L'WWeli Contractor Information:
IA.IVA—tER.ZON E.q
Chris Ruffer FRONT. T I ovicRurl lox
Wel(Co.rArtdorNantw
n. n.
4223 A '
NC Well CordmciorCcnifrationNrrniicr 15.OUTER CASING tfnr nnitti-cavrii'iveucl OR LiNER(if.a `llcabkl
FRONT I TO nm imTER. TiiICTCNECti �I;\TER7A1.
SAEDACCO Inc ft, fL ia.
CCircTranyName ld.INNER CASING OR TIrBING 41ea16crraA clo-Ld-lunp)_
FRONT TO 1 MAMTEit. -TIiIC[u�TESS IL�TERl\L
2:ell Construction Per•alit#: 0 ft. 53 ft, 1 tl! Sch 40 PVC
Lirlailcpfiliaiblaxrllpermits.(Lr..Crirrnhr;•Shnr,.lrnrinrrcr.ltyRtr'dlarc:) ,rt., it, in,
3.Welt.Use(chcct..rrcll use): 17_SCREEN
Water Snlilil\'VV!r h FRUIT 170 DFANIF.TER I SLOT$17,F: i NATERIAT.
C�tlgliellltuTal t�tMlunitip l!t'atlTGc 53 ft, 63 0• 1 io• .010 Sch 46 PVC
C7CireothcTmal'Mcitine o4ling 5141ply) DResidential grater Supply(single) ft.
DIndustriaUConmicrcial MRcsidcmial Water Su f4•(slrtred) t8-GROUT
pp TROIT TO. ITATERML Ed[PL\CCiILNT ITETHGD&A.1TOT3NT
❑lr i'ation 0 ft.' 47 (C Portland Tremei
Noti 1Yater Supply Wpll:
OxIonitodrig MRccoN-qiy
Injcetion We'll: rt. (C
❑Aquiterge0irgc MUroundvs-nicr Rcrticdiaiion 19.SANntGRltreL PACK ilraiitiCJGCen-
FRnar TO Itn7t;Rrar. Flirt\rF:IIF:VT siF ruon
MiIuifcrStoragenitdRccovcoik' ❑sllinityMifice 50 it.. 63 H. sand 2
❑Aiiuifcr?cst ❑Stormwat&Drrivage
❑>rxperimcnt317tilrncslA,�� ❑5uhsiit�ir�c CQlu7pl
'10.DRILLING'L.OG(atlach additimual Aeets if aeccscan•l
ElGeothemutl(Clusedl.00p) 17Traci.K FRONT To DESCRIM01%,roalor.tianLivo.S"Irnlekhiq:` Wote.ie0
❑Crzothenrial(Iira[6►ttrCoaliue.Return) ❑Outer(explain tinder#2 Li Retuail s) ft, it,
rr., rt.
4.IIeteWe1t(s)C0rt1plcled: 4-14-2022 ,AW111D#OW-49 '� 1^
See Gap s note3t
5R.,NVell I.tteatiou: (L ft.
MAY
Chemours (L rt 022
F:rcillIpUivnerNanc FacpityIM"(if applimble) ft. ft. ilflrlriTri^,;;� ?
1248 Bill Hall Rd White Oak, NC 28399 Cumberland C, ft. ft,
White Oak, NC, 28399 Plivikidar "s-.Ci[}'.an0ZIP 21.REM1LARKS
Cumberland
Ct�}iut�' l xte3ltl.r0&,.j6pu No.(PIN)
Sh.I iltitii tic and Lan(;tttnlc iTi direslminutcslscctinds iir dcciin 11 tirccs:
(i6vu frcid,oia L 104 i Srr(ticktrt) 22:CcrtifitaHttn:- �p
Chris [�IXu{1G_1 _ C' 4-14-2022
Sigmwr afCenUSed iVell CanteKtdi Dale
6.Is(are)the well(s): $Permanent .or LlTemporary. Ify.srgning i6ix ferrra,r hereby ceirifv rhar 1hr n•eR{v)t:as(wen)conAirucmd by aeordmice
kith I5AjMtC-02C.9100 or..15d NCdCMk.0200*elf doirstrirdorr Standardsaialrlaria
7.b"this it npairfn an esistingwell- ❑Yiw or ®No ctrit..ojr(i{:r'rraurdlassJaerrr frrnrir&t1 raiirr In 11 mrirrr,
{Ca2ylr�, rr�rlr.Ali czar ura irw Ivelf the mirure of rlie
i'�vcrrrcmlrrd r mvJr,Cr:s>tr.icoii arcvr the lJOA ojthts form. 23.Site diagranfor additional well details:
You way use the back of this 0&6.proc'ide additional well site details.or lti'ell
S.1lumberof wells constructed: 1 confliction details. You maT also:uitach additional pages if necessary.
Far am+tln'rih+i'rtt'cr�rtiulti�riiai-Trent r�i�p ir�c7lr r)1A'Z}'irilh rlie sirmd cdrrsirirctlwr,ytra.cr�7
.rmtwrttarria,fi:r%a.' . . S1TBM1fITTALfftTSTCTCTIOl4S
9.Tofal bell depth hetoii land surface: 63 (fl,) 2da. Far All Wells: Sitbruit dds fomi within 36 days of conrptciion of c1l
For mritrJpQ its€ilsl(sr irFt+li u as'tj rfl strait f,ran Pr.i m;tall'nrnL?+a ttk7)' constntciion to the#'altoning;
10.Static water level lielow top of cusiutr: (jt,) 1111'wdu of Water Resources,Information I'rucessing Unit,
If*av-erleveI k,isboty cursing,:use"+" 1617'hiail St:n•ice Center,Raleigh,NC 276994617
II.Borehole diameter:6 in (in,) 24b.For Tujmair WeRv ONLY: In addition to sending the fomr to the address in
24a a€ioi•e. Aa submit a coptii of this roan within +4 days'of completion;of"hell
12—'Well'coustruction method: sonic c�tiSttuctioit t®dt fsilloniisg.
(1.6.Mig'-r.roimy.'cabte rlim-t push c(p:)
Divliion of M1Vater Resources,Undergrotind itijecilon Coutrdl Proarim,
FOR NVATERSUPPLYNNFELLSONLY- 1636 Nfail Service Center,RalciglijNC.276991636
13a Field(glim) Method of test 24c.For Water Supply&Inicction Wells:
Also subriiit one copy of this font %ti,Ubin 30 daysof.conlpletionof
13U,bisinfLvitinityPe:, Amount: well comstniction to the county Itealih'department of the conntyreherc
constmcfed.
Fonu G\V-1 NoPh Carolina Depawwrit.or Emvironnras and Named Resources=Dfti;Ion of SVatcr Rc5owc s Revised August 2413