GW1-2023-02631_Well Construction - GW1_20230410

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``WELL.C©)NSTRUCTF®N RECORD For Imm-d Use ONLY:.
This Corm can be mcd tui singtc or nrultipk rweIIs.
_ fl.��`l'�t CU11LliLlNP IILI'ltrlt11Ll0tt:
Chris Ruffer Fnr)M W nF$(atrr G,,*
Will Coii r.wor N nw
4223-A 7
NC�trclt CmdtactorCcni@r nionNutrlict A rD R !t Q 2l'n
23 `t5::©UfER CASING ifbr aiutti rawc�llscFTsi OR LINER"lif a i`t"Abld-
FROM TO I nr..tttST6R TFUCF'CESS \tATEMAt.
SAEDACCO Inc
0 f4. 50 (t. 2" in.. SCH-40 PVC
4anrjrtrupNapw
ri+=;,; :;+ NNEELCAS OR-
(NGitiBING i�i6erinateCuscillain►
�•,:.:L.;��Y •° KA
FROM _To I MINIETCR -I TMCt+NESS I NLkiERLkL
2 Writ Colistr uctom PoTait R; R. (t. 11L
1iFt all cpplira6frxcllperrrit; fr_c.Counh,:Swo.,Iarfalwe,ltbs:odlzfr.J FL
_ rt is
3.FFclt iisc{cPlccla`cll use): t7:scatty
Water Supliky WelL• nn(rir t0 arAurTr ri sr.r)rsrzr, Ttnct�wt+s uArrn(ar,
CJ:lgticullilial L'lhliitiicip:IUT'ttlilic 50 ft, 55 ft- 2" in. .Olo SCH-46 PVC
Meothennal(Hwxingt'Cooliug�Supply) ®Resldeiltial Water Supply(single) fL
©lndustriatiContotcmial ©Residentiat grater Supply(sleeted) AS GROUT., -
PROM TO. JLATERDl. I EMPLACGM 31MOos.1010 T
E31ni lion 0 ft. 40 ft. Portland Trieme
Nun-��':adcr Sutlp[y l\!eCC: t4 (t.
Edhlonitrieing 17Rccowry
tajecl[on welt t4 r4.
-L9 SANDICIIAYHLPACK7if•l ttl:'. _
L7AquifctRcCliargc !aG►nundtratcrRcnLzdiatian rlic�b
Ft:OM t0 �t ATFLRr.A�I, f?51Pr�tCF�rF:r1'MFTrI(rn
❑Ailirifcr:St4!agc and Rccovtc3' ❑salinity'hairier qg R. 55 ft, Sand #2
11 Agtufci To Orkir4lgc
Cl incripicalal TcchnQlogg []snbsidcrtcc Control ;DR1LL9 iG'I OG 7altach additiuuialsttLets if iFctt san'l
DCeotlrr rilril(Closed Loup} OTr14'eI FROST k l
EGG otheimal4Heating(Cooting-RetwO ElOther(explain.index--921 Retuarls) t4 ri
4.Date
IV&(s).Q:ouipleted: 3/15/2023 WeljjD#SbWtJ350-MW62-55
fL 'See GOO 3 Notes
54.Well Lomf nin f4 (4
Camp Lejeune SWMU 350 ft. ft.
Facr3ity,Ono rNmac Facility [ilk tifappliablc). R. f4
84 Iwo Jima Blvd., Jacksonville, NC, 28543 ft. f4 .
Phy3i".,irl Address.City-i"Zip =:21:HEhiAR[i5'
Onslow Bentonite seal from 40-48'
Cvnul�• P:rrcc]1Lk:atitYcyrlpn NU,(FIN)
5b,I-Aitude auif[.nnfiftude in 1tt tirccs/minutcs;s+econds ar decirit;il dgaWs: 22.Certitrea6na-
(iru ell fxld,One l:blor>o i;;srdfixiod)
N w Chris Ruff_er•' 3/17/2023
Si�hurr of Cctificd iVeIl Canrraetor Daic
6.ita are the:cells}: XPenuaneut or ❑Tern ra f n' s;'gnnrg AWs famr.l hereby Lyrfify rhur thr rrellfs)rwr(w&rej en-yi ircred 5e acranism
iHM 15A NCAC 02C•Okw o'r l S;l NC,lC O'C•O:P(1{ti'(I CO_�iFrr h'.ICrI$rU7i QftlS tf,kf rlklr ti
7.Cc tfiis r eLliaii to an etiitis.:nc11: OYL-s ,ear 1r4No iz n ofrhir rrrtinil,ris NVA rMlie d(urbr.:;l J1 mrn<'r,
1/)h(s:1%a ttralr,fi11 qrr kr,r»t'rr well rcrutwok brjprtmfion arul t rpinhr the+ulnae of die
repair 021'remarU secriorr aran the burl of teas'fnrnr. 23.Site dlagr am or additional,well deluik:
you uray use the bacL_of this page ta:ptocdde additional well site details:or belt
S.Nutuber of hells wustmcted' 1 constrction details,: You 1114y.tlso attach additional,pages if nocessury.
For ritahipJe hdecrlo)i oratin-never suppJy teells ONLY i4rh the strttre en,rs iedon,Sou ecda
salmdt acne forrn. - SURNI TTAL 1NSTU€_TiONS
0.Total Welt depth beloic land sdri'ace: 55 (fl.) 24;c Par All `t,abc Subunit flds form within 3u days of,completion of Yell
For,rra h1ple hells list all dep,hs 1rdi eren,(t'.rtralm(a M�200'ml&2@ 1MY) construction to the foltoning:
W.Scatie Wate-Ied•et below lap Gf easint„ ((t,) Uivbduu of Water Resources,Infnrntatian 1?euiessing Unit.
if uvav level&above age"+" 1617 Ili tii Serz'ice Center,Rald-gh,NC:27699-1617
11.linrehole diameter.6" (irr-) 2Jb.rn o l n �'•l c flYI Y: In addition to sending the fomt to the addtess in
VSabot'e:.also submit a.copy of this foutL within 30'days of compictiau of hill_
12,Welfconsiructinnmethod: Sonic Loustmcliontodiiefotlo%iing:
(i_c. uocf,rot u ,cable.dirai prLsla_etc.}
Divistmt of Water Resources,Underground f4jectiatt Coutrol.Prograin,
FOR WATER SUPPLY WELLS ONLY. 16361%bit Service Center,Raleigh,ETC 2 7699-1636
l3; �cld Metbad of test: 2 fc For�l atcr Suplilc& ctftin
& (Spm) Also subtWt one copy of this £drib tcithiti 30_day ofcouipletiouof
13b.Dislufection ty it. Amount: well Construction to the county h'calth department of the coiimy where
1' constructed.
Fa an Gttr-I Nonh Ca oluLz f tipanr¢CrU et FavirouuucuU and NaturJ Resources-D1vi;loa of Rratcr,Ri=-aLec, Revised ALgust_Vl3