GW1-2022-09154_Well Construction - GW1_20220930

'WELL CONSTRUCTION RECORD For lrternilUscONLY:
This form can to used for sinpk or multiple rails'
I
1.Well Contractor information:
IL WATER ZONI S
Chris Ruffer FROM TO DFSCRIPTION
Wc11 Coitti:tctor Name (I. (I. i
A. h.
4223-A
NC Well Contractor Ccn iricai ion Number 15.OUTER C SiNG',fnrptuhi aped aeBs;UR Li M 61140ikahk
FROM TO TItAMETER- THiCWVF," MATERIAL
SAEDACCO Inc 0 ft. 7 fl. 1^ in. SCH-40 PVC
CoIi IF;oy N.111sC 1d INNeR C INC OR TU81NC'1 ieoIbermat dowd-lair
FROM I TO I DL,%MVTER I THICANIESS I MATERIAL
2.Well Construction Pel7nit fi: tI. rt. tn•
Lilt till apphrable well prnnits(i.e.C,mintr',SLrr.,1'arinrirr,I IX'GtYt rte.I
3.Well Use(check well use): 17 SCRi.1:N
Water Supply Well: FROM I TO DIA%tF.TTR gtgT$t%E THI(RS^'% I MATFRML
bAgricultural i muoicipallAlblic 7 h. 12 fb 1" in• •010 SCH-40 PVC
Mothemial(Heating/Cooling Supply) 011esidential%%later Supply(single) fl fl• in.
Oindustrial/Commercial 011csidential Water Supply(shared) FROOa�RO� 70 MATERIAL i EMPLACT M"I MCTTIOD tS AMOUNT
❑fro ation fL (L
Non-Water Supply Well:
MMonitorinG ❑RecoT•cry
injection Well:
DAquiferRecharge DGroundw rlcrRcoicdiation 19.SANDW.RAVELPAt Kfir itk5bfe "
FR M TO nfATn:Rnan, NMPI A(*,MKNT."rr"OD
❑Aquifcr$ionSc and kccosrty ❑Salinity Harrier fl. ft.
❑Aquifer Test ❑StonniTnicr Drainage fI II
❑F_xperimcni;tl Technology ❑Subsidence Control
"20:DRILLING'1AG`allach addilionnl slims if necc<sarr)"
❑1[reathemtal(Closed Loop) ❑Tracer FROM TO DFSCRIM,ON(evbr.hardnv",wa'nrrttr . ridve.W.1
❑Geothernial(Neatin,lCoolin a Return) []Other tex lain under b21 Reularls) See gho s log ft.
4.Date Wells)Completed: 8/29/22 Well(D)p TtIW-3
53.Well Lttcathm: S F P 3 Q 2022
NCDOT ft. fl.
Fac1ily10wncrNanrc Facilitv'1Dk(ifappliciblc) r "fait­�ff'%4Aftnu jnf
fl. ft. `,�l�r` i1(i
217 US-701, Four Oaks, NC, 27524 ft. ft.
Pl%sical Address.City.and Zip Yt REMARKS` "
Johnston 1" PVC temp well for groundwater grab sample
t:denny lrartel Id u0frcdiinr`tJK,.(PIN)
5h.lAititude and Longitude in dcgntcs/minutm/seennds or decimal degms: 22.Certification:
(if well Prod,one hdlotq;is sullickni)
N W Chris Ruffer 9/9/2022�_ ,
Sigamun:ofC-cntficd Well Contractor Date
6.1,(are)the wellis): OPennanent or M-signing this fioim,/hereby e'rrfify this ihr u,r/11s)i,vrs(Nerr)i-enivinected irr aceordanre
16th!SA NC14C 02C.01W or 1 Sri NCttC nXC 0200 Will Cr'rngrorrinrt slon'tards and I)MI a
7.Is this a repair ft)an existing well: i7Yec "t)r Kt No ropy of dtirr reronl has leerti finwIded to flu'rn•!t mener,
if this is a wpoir,fill om tr(iMA wea amsinfoltrn brfori sjaykmeirul ei laht the)ware of the
relmir w der P21 rrmnrkv se—e-ion or r An the Merle ofthh farm. 23.Site dial-rain or additional Tveli details:
yol►nrTy.use title,back of this page;to providee additional well site details or well
9.Number of wells eonstnicled• 1 construction details. You'ioay also attach additional piges if Ilecessan.
F'o'Ir�,mnhlple ietlecihrn of non-wtrer mpp5v er effs MVIA 14rh fhe some construrction<you Can ry �y
s aNiUt Anr form. SUBMITTAL. INY`411 I O N I
9.Total well depth below land surface: 12 (ft.) 24a. For All Wells:. Sulontil this;font within 30 days of completion of well
For mi,Mpfe e.elis list rill depths if different(ex&mrle•361200',iml 2Gn IM) constmction to the fotlmiing;.:
10.Static water level below top of casing: (ty) Division of Water Resartrccs,information Processing(snit.
if-watev level 0 urbane ce4itng,use"<" 1617 Mail Serriee C:eater,Ralei>;ir,NC 276904617
11.Borehole diameter.2.5^ (in.) 24b.For lnl(rtion Wells ONLY: lit addition to sending the form to the address in
243 abo%'e. also submit a copy of this form within 10 days of completion.of well
12.Well eortAnlction method: DPT Construction to the following
(Le.anger.rodan,ciible.Aitccr push crc.)
Division of eater Resources,Underground Injection Control Pmgratn,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,:NC 27699-1636
13a.Yield(fipm) Method of test: 2Jc.For Water Sunni'&injection Wells:
Also submit one"copy of this fornir w'ilhin 30 days of completion of
I3b.Disinfection»pe ____ _ ____ Amount . well construction to the county health dcpanm;tit of the crnmty.whcre
constmcted,
Fanu G�1r•I North Caralbta DcWnnuen(of Ernirorweta and Nawrat Resources-Division of Wiley ReSottt- Revised Augui#?O13