GW1-2022-05184_Well Construction - GW1_20220531

WELL CONSTRUCTION RECORD FarW-cnml Use MY:
nis form can be used Col.single ar multiple nvcl]s:
1;Well 6jit'Oorinfarttlation:
1J:\�AT1:IL'LONk$
Chris Ruffer FROM .TI} b"CBiPTiON
W01£caxtr dnrrgarng, ft. Ft.
4223 A ft. ft.
M Well CanftactorCartifscAoij'Nitirber 15.OUTER CASING(fn�mtill-eascil.welh)OR'L1NER(if n f alNI-111
FRO31_ T4 DMIETER THIC[iNESs aT.eTLR1AT,•
SAEDACCO Inc YL, (L in.
Coftgnuty Nanrp- MANNER CASING OR TLsBING4' mhL!ranal ckased4oti r
FUMT 1 .70 DIAMETER., I TTITt'6'NM I MATMkL
2.W41 Construetion Ocr Iti t is 0 ft. 40 ft, 1 ua Sch 40 PVC
Lisp'trlrappildrablr v.d1ponnits fr_r..Caamto;-Stirar,-lrarpaace.l{yerdga rat.} ft. ft, „i!a
3.NVc11.Usc(elitxl..ncll use): t 1:SCrti:EN
NVaterSupltly U&ll: FROM TO arANTRTFEt .4LOYS17.V TNIM-NISS MATRRIAT,
LSrtgticnlhtTnL 0.Munieipal f'ttlilic 40 1t: 50 (1. 1 iR. .olo Sch 46 PVC
OCto(kin1al(HeatineCooling Supply) DResidential Water Supply(single) B` f t W.
®IRdustrialfConmtercial ©Residential Water Supply(slmrcd) FROMROUT TO. DTATERLu;, E1TPUCE 1TENT INT6TIIOD S A\TOLINT
[7frii`than 0 ft. 33 IL Portland Tremei
Non-Water SupplyNV.e(l:
gManitoring ®Rcco%-ciy
Injtwn,Nveu: ft. rL.
dAtidifcr ltccfiarge MGrouliftitcr Rcaticdiation 19.SAN131 GR \'lL PACK fit a i rGeabtrl
'FROM, TO 'S1Ax RfAr, R,.1PI.AC.1:v1.NT)T"nl7u
C]Ai[IiifCr-StorlaCeiulRsCnN-CTy i7SalinityBarrier 37 It,• 56 ft, Sand 2
❑;tigiiifci7'�(. ❑5tomifiltciQr,Tiiitgc '1t. f_t.
EI Tirncntal 2h11nolog'. 17505idcnce C014r01
`20.DRILLING LOG(anach additional shcMs if mcecssan
gGPttllteiTunl(ClpseclLoop) OTracer FROST.' TO RMCRIPTION'Nolor.hardiiev(.willmiek tw.`gxA0ttc,tot.)
17GeoillennaI fFleatioe`caoling.Retutul ❑Otlter-(explain tender 921 Remarks) fy ft.
4.Date•NYeI[(s)Coplpl:eel: 4-4-2022 1W` ID#OW-43 See G>;Q s noteriL
{:T:Wdl Locaition.. ft. fL.
Chemours ft. (i piC•C,c^„ ;•,
Facl�ityaC)mticrTTrtmc Faicilitr 1Dn(iFspplicab16) ft.- (t. ;`QJzpG
1248 Bill Hall Rd White Oak, NC 28399 Cumberland C, fk.• ft.
White Oak, NC, 28399 Pltsiicii)Xfidicss.Cat�:aildtip ;Z1.REht�RXS.
Cumberland
County Nrtcl idenGCrCviou No.(PIN)
5h.I,.ai➢tilde aijil LIiu-;iinie in degtres/minuteslscconds or dccimal dcgreck 22.CcrtificaHoa:-
(ti,.tiltl tTeltl;t,.tre 1;t41otda SrchiCsid).N W Chri' ,, Ruffer 4-4-2022
SigrutuceafCictUrilwellcaric adi Dale
&Is(are).the.well(s): MPernianedt .or 13Temporary.
Ity-rlgnralg ihte fdrrm,-.l hereby certify rlrar rrie.irrll{s)tsar(N'crc}reakimcred ar.aceaj-4vnce
inch 15,t NCAC O1C.4T1 PO or..I,f t NCAC 0:.'C..O209 J►elf Cwista iertwr Standards mid fliers
7.Istithaicooiitoanc.istingwcII: oYcs' .iir '®No r 4' i ,rr�r;r�r.
7;fatrfs:ds a t€,mrdr�r1 cnvrfir�+rlw scx1P lmrctta2a it(,t+ammaliar enal rt�ralar alrv:rrtarnre df ells '.
rq'1ir`r1r ttim•Itr A?1.mrn.irJCsaicxacim ni-cvr tGc baik'nf dies forur. .23.Site d dgranr"or additional will details:
You may use We Bach of ibis i agri,6'.0`r6%idr.addi1i6nal hell site,:details,or trell
8.Numberof ikelh co tiructed: 1 cons(nxtion delaifs.`You ntay als<r:ailacli additional pages if necessary.
amour mairrdrJa dr�Yak�r.a»�rau�i-irwrer sar�v'rr+erls:AaVL}'mddr rlie.saawa+raustruellrrn,ycart�lra
.tarNardr inq.y�ariN: .. .. -S UBMITTAL INSTUCTTOriTS
9:' ivUl will depth below-land,sdrfaric. 50 (ft.) 24a. Fur All Willn "Submit this fomt within 36 days jot'eomplelion of well
FOFwalfipdril�C,tr'1rsaatPlde '(f dw,rrail(e.xa,MPte-3@:00'and 2@'l I con5tnictionto lhcfoiWseifigi
10.Static Water level below top of casing: (R,) Ilitisftin of�}'titer,Re�iourrci,Informutiiln Ptticessing Unit,
1f iprateiP revel�abaie ctasraiz;aase"�" 1617Afail S�•icc Cctilcr!1R:11ci�t,1,.NC 27G99-1G17
11.13orcholc diainctei;6 in ( ) 24b.For hv[a ad WON ONLY: In addition to sendingtli11 fbinn to ll)e addiess•in
24a aligtve.also sitbruit a copy of It&-fonn within 3f1 days"of completion,of x�il
12..NN`cl,fcottstntctiou m�i6od: Sonic tUnslntctioti t®'tit follosvlti _'
(%c: ugcr.raAail.:caibic disco push etc:)
Division of N'Vatcr Resources,Uadcrgronnd Injcktilon Control Program,
FOR NVATER SUPPLY RTLGS ONLY: 1636 Malt Ser•t'ice Cenler,Ralek-IiiYC 27699-1636
13a= °iGd(gpm) Method Of test: 24c.F6C Welter Supply&tnjcetllin%Wefts:
Also suliniit une'copy of this forth witbin 3Cl'days.ofeomoletionof
131).1113infLiiian,ttype: Amount: ,.tell comaniction to the county lidnith department•of the.cotiniv-,vlBcre
constrtictod.
FomiG\114 ironhCam1hiaUcpanmentofEavimi mutandVamralResources-DivisionofWatcr,Re5 trtm RevisedAtgtast'fo13