GW1-2023-01939_Well Construction - GW1_20230227

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WELL CONSTRUCTION RECORD For lownial Usc ONtY:
T1nh fmm can be uwd for single or rnu tigk hells
I. el 1.Contractor Information:
li.WAT[1R ZONES
Chris Ruffer FROM To I DOCRImON
t%01 I marmot hank A. a. -
4223-A n. (I.
NC Wd1 Contracter Ccnifmumtmon Number IS.OUTER CASING(for amuM!•aud wells OR LINER tit ticahk
FROM TO DLtMETER TBiC1iNES5 M�TFgltl
SAEDACCO Inc 0 (1. 37 ft. 2" ia. SCH-40 PVC
Compost)Name 1 NG Olt TIl64NG 4ambermal chrovd tomgb)
/ROM TO DIAM[TYR TnKXNFsS i Mi11111 ILI
2.Well CAlrttlrsctlun lbrloit fF IL ft. ilk. - -----
Use all appUrable mvilprrn ifs(i_r.Crmurlty.SLAB,Variance,lfjaraG=err.!
3.Well I;se(ehcck well owl: 7 N
Water Supply Well- [7371L
TO DItMeTi:H sl.orswy Tut(xrrtnS N4Ts'alal.
[)Agricultural 0MunicipaL'Public 47 fi• 2" iw .010 SCH-40 PVC
DGeothemal(Neming/Cooling Supply) OResiden ial Water Supph(single) n su
OlodustriaUcomRmercial ❑Residential Water Supph (shared) 18.GROUT
FROM I TO MATERLU. EMPLACTMENT MEHIOD A.tMOUNT
Dlmgatwn 0 R. 33 A. Portland Tremie
non-Water Sapply Well: ft.
60ht011110nng ❑Reccnrn-
I0*1ion Well:
❑AquifcrRcchargc ❑Groundn-aicrRcnmcdiaflon VEL PACK af *bkl
to F'MPi.1t rMriT MVTHOV
❑Aquifer Storage and Reco%-cn ❑Salinity Bamcr 35 B. 47 rl. Sand #2
❑Aquifer Test ❑Stormwatcr Dminage
❑Eglcnmcnial TechnoloLN ❑Subsidence Control
20.DRILUNG t.OG(attach attditiousl slurels it necesun-I
❑Geutltcniud(Closed Lxrpi ❑Tracer PROM TO OF-WRt►TIOV sw4r.�ardava,M,4'nw4 •ivmr.Nr.)
❑Geodwinial(1-kiting,(ur lmi:Rettilm ❑Other 4explain under#21 Rematti:s) k n.
n. ft. a I 1 �~ i
4.Date Wellw Cutupktled: 1-23-2023 Well IDrIBladen-lD-R �-
n. See GBp' 11 Notes FEB
SIr.Well I.ocutarn: ~
n. fL r
Chemours FL It.
l n PfOG4siilSg Unit
Fac0d,,,ClhncrNanmc Faci]4IDN(if appiicibk) _.
ft. fl,
Glengerry Hill Rd., White Oak, NC, 28306 R f4
Physical Addiem Cit).and Zip 2! RICIMA!lIG3
Bladen Bentonite seal from 33-351; replacement well
r :u,r. I'.ucel Idcnldlcatimi No (PIN)
Sb.Latitude Audi 1.1111gitudC in tk-t!rresiunnuteslseeonds or decimal degrert: 22-Cerdfkatiou:
tisl mNcl:1kid.unc IatJoug i—idhzk:id)
34.8146657 1\ -078.8325898 W Chris Ruffer 1/23/2023
Signilars of Certified Well Contractor Uaie
6.Is(are)the well(a): EPermwetrt or ❑Temporary ftv mgming tll,is j6M 1 hervbf•tvnv% that NY'AYlks;Mow(Mr1r)ex"utMr'Ml 1R avrordancr
with 1 SA)VCAC 02C.01o0 or 1 SA NCAC aX,P20f1 Weff C ratstrw-rion Standards and char 41
7.Ib this a repair to as esirtioR well: ZYes or ❑Ne i><ry afihiT record has been provided to the twil rummer.
If r111a is a repair,f ff our W,14"well c otblim min mforn oskmn tnd explain the narure of rhr
repair sunder t21 rrwiankr sm mn or ari the bmI of Mar form. 23,Site diagram or additional well details:
You may use the back of this page to provide aMliotal well site details or well
S.Nwoberof wells c0nnniected: 1 conslniction details. You mnay also attach additional pages if necemn.
For nWrrple iwfecik-m rH rows-n+seer wppA wells ONLY ndth the swine rtrwstrurtwx %4v rvnv
aabmir omr fornn. SUBMITTAL INST (CTIONC
9.Total well depth bebw laod surfa= 47 24a. For AN Well Submit tlis funn 11 ulnn 3U days of completion of 'hell
F„r,nr,hrplr wells hse fit)dqrh,i(�ityr'irrulr•ranpnplr-?�:(XI'aw1:@'IlM7k construction to thefollolling
10.Static water level below top of casitiv. Al Dtvisiun of Water Resourxes,Information Processing Uot4
If reviser level is above rasing,slur"+" 1617 Mail Service Center,Rale4h,NC 2"6"-1617
11.Bnrehok diameter.6" (ia) 24b.For I0 jK floe W'elle ONLY: In addition to sending ate form to the address in
24a abote. also submit a copy of this form A ithin 30 dm s of completion of well
12.Well constraction method: Sonic Construction to like following-
(Le.auger.roan.cable.direct push ew.1
Dh'hmlon of Water Resources.Usdcrground InjetUoo Control Program,
FOR WATER SLTPLV WELLS ONLY: 1636 Mail Service Center.Rakich.NC 27699-1636
IJa.11clJ Ittpml MCttwJ of tsltest24c.For Water Supniy&Injectim W'ela:
Also submit one copy of this funs within 10 days of completion of
1Jb.Disinfection n pe: _ Amount: well construction to the counn health department of the coustf wbrm
coriwmltcted
f;rnil(it(-I Nonh C7aolnms Dee mmem of Em itDnimi m and Natural Resomeea-Dis•tsion of Water Remutrs Rem used Atmet 2401?