GW1-2022-05167_Well Construction - GW1_20220531

WELL CQNmucrm RECORD For Ucnwl Use 6NLY..
TIT's form sun W:userl-fm sNrloei moltipk swils'.
I Welf6aittattorbiformatiod:
I.I.lvxutt ZONIS
Chris Ruffer FROM: "I "FSCRHMIOX
11'�lCoi�taclrrrt+rame, R. ft.
4223 A
NC Well Contractor CeLl ir=t6a Njutli& 125.OUTER CASING(for molikaw'd*M?!Tj aLIMIR flis!s I'i'l Ind
FRONT TO, DIAMETO
SAEDACCO Inc fL. in. I I
CbtrVmLy,Mangy. M.INNER CASING OR TU8ING41,9,91her it
FROM To DMIMETER-1 THICKNESS I MATERIAL
24,wall Construction Vrimilit 0 H. 57 ft, I Sch 40 PVC
1.W I'ark"WO.,frftCtfCn 111.)
ft.. ft. in
3.wom fi 'I CrIC"A use):
setal'EN
water Supply'vVeM.- FRONT TO nrx&rF.TFR sr.oTsizx. I 7H1"-Nt1'5- I'MATERIA12
57 67 fi, I old' S6h 40 PVC
Mgdcultkilral
Mco(harml(Heating/CoolinSipl ) DRasidntial AVIi terSupj) SiDgW) in'
gpy ,(131ndustrial/C6ninicicial MResidcutial Watci.Suppt-,(shared) 18.GROUT
FRONT TO. MATERIAL, ENTPUCESIENT AWMOD&AMOUNT
0 It. 51 it. Portland Tremei
Non-Watir Supply IWOM,
ft.
Nia n ito n.rig
Injec.11tott Welt:, ft, rt
DAilluter'Rcebairge I9..qAND,'(;P.4kVLL PAC(Ir'applicabte)
i : '. . - sfxrtzatm. P AIPJAC.LMENTS]"1101
QAqinfcr Sioa�i andlecovefy PSatinity Ratic 54 'f. 67 ft, Sand 2 fj; qurfcr'T`cs-t w-Itce 6ntip't"C ft.
It.
bl�Xparimcirtil Tcchnotogy ElSubsidencd Caiiiwl
6Geothennai-(Closed to p) 13 1 Tracer 1O."DRILLING IDG(rillach addiliooal,shecls if necessary)
FRONT- TO OMCIUMON-fca)sr.Ntralimi-SoUlpick bvC."p-Afin sirv.tic.)
13436otherma I'(fTeath%Xqao11 ugRennn)'• Witter(explain under sr2 lRemaiks)
f4,
4.DAtie�y6lt(4)qmpjiIgd.- 4-8-2022 1%VellID#OW-21
See Gfto s note$L
So.,-NIVI LAication'!
ft, M
MAY
Chemours ft. I'Ll
I(i(applkawq)
ft. ft.
1248 Bill Hall Rd White Oak, KC 28399 Cumberland C, ft, it. 91
White Oak, NC, 28399 PhtSxidtltldress 4P 21-
Cumberland
Farce!
fib.Liititicic'anil dc!
( -uil d,' Al 7,qqpvc�,itrintt,61. 22,Ceicatiorm
if 1641 Me) 06�, �4,i)
W Chris- Ruffer 4-8-2022
signawl;��Well co Himaalf- Wlc
Lry kereby certify 1�jutr,14 iref4x)way(�rrv)cmerinfered hr WWOA67re
iikh f5i1 jMtC 02C,0100 or IJA ArCtIC O-M,02017 Well d0j,;1nicdbn Standards a'nd 47i
u s a* xvissur,to anixi.Nting.well: 0yes ofaif'r,"10d 60-5,bech pq"*,?cd tq'ifir-lint awifer.
7.-b this or Ooi
V I is"Is a twit j64,w well d cm 1�xfifahl the mpire qfrlla
14
rEMir dtdirkll FEM,ilrk'eN�ECAuU Or nq die.bf;Cl-Of Phis 23.Site diagram'or additional well dewits-
You,m#-Hie thaba&of this pa'g`e,66'."Provide addifioiWwell Site.di"of iiall
8.Nimberof Wells con§tnicted: C.onsttuctidn de6L-;' You fiiay also.attach additional pages if neces.sary.
kormr4d#d ff*ahwl ,6w;4,�ei jvp�rirdh.ONLY uldi Op.mmi can
SUBMITTAL WSTLICTiONS'
9.T�lial,twell4eptli,ppt,*,T.l:md surfacai 67 24a. Par Alt 3�`e . S46fidt this fftnu within 30 days.of-contpkdion of Ivell
For*MITWO M I 6risiluciiPit to,itic;fq1to-vin ng;
10.Static water lael helow top,of casinW, Dlvisimi of Water Resadrci.-4,Informotidn Pr6ceming Unit,
1/ftwieth-vel lr iota cruaert use 16 O'Allnii'Sc ff' icC C`cnter,Raleigh,?4C 2769-1615
Il.g...11,1adiornater-6 in Ain;)
24b,.For Infaliflit Weliq ONLY., Twaddition to sending the form to ilia address in
24datio,via. aIs.o'E�Omjt a copy of this iolnii witun.-to days of completion of Hell12.Welteaustniction method: Sonic to tit--f0flu,M112,
gush etc.) Division of'*Vater Resources,Uti&rErriund injection cou"I grogram,
FOR WATER SUPPLY WELLS ONLY:, 46M Mail Se'rVice Center,Raleigh;NC-2769-106-
'24c.-Fiir Water Supply&Injmtl�n Wells,
13.-k field(glint) Method nftcA:
Also submit One copy of this fonii ivithin 30 daysofcompletion of
Amount;
well construction to the county health c1cpartincra of thc.connhr.where
Fann,G%r4 North Caralhu D0.pwmxm of-Eavironrocu-add Nmtrra].Resources—Diviii6n oMlater-ResaLra5 Revised August 2013,