GW1--05805_Well Construction - GW1_20230912

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WELL CONSTRUCTION RECORD• .
,. For Irternal irscONLY:.
. This form env bo used for singlder multiple wells. • • .
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1.WelICtintrattot Information: . •
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:14::.-_UrATERZONES •. • ' ' ' • - - .•
. Chris Ruf fer . FROM lil DE.settiFTION
WI Comm:tort:am- . ft. ft. • I
•• . ft. ff.. I I
9223-A • 1 , .
-A&OtITHR;CASING IfiiiiiiiiitlizcikillittliFORLINERAVAlfilksibk)', ,. • . .
NC Well Contractor r''''......ni kali iDIA W.,m.b........,C1
FROM ' 70 " • DIAMETER' THICKNESS 'MATERIAL
. It, ,- ILtn.
SAEDACCO . •
CsmDanyNortr- _ " . .
'46:::IINNER.CASING'OF_CTUBINOtt:0311Mirtalekii.C1-1jiye',' -
• FROM • TO . - DIAMETER THICILNESS • MATERIAL
2.WelitonstruetiOn Pertnit II: • ' • . 0 R. 5 ft. 2 . SCH-40 PVC
..1,4-iirllapplfrabk ircilfpcouirs.if.c County.SIal-P.Itationce.frejec04:(.1,74
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fi.- rt. • •: ht.
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3:Weil.Use.(ChecicWellass): • 47:SCREEN. • ._., .
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. • Wafer S.R1:14 _. _Well: FROM TO utAMF.TRit st.OTSIZE iriiittcrias. 1 31ATRRTA I.
"- - - -• 5 11,E 15 ft. 2 14 .010 SCH-40 PVC ••lAgficultitral ' ' MitiniCipaliptiblic
• EiGenthermat(HeatingiCooll ng.Supply) ClResidential Water-SupPlY(single) .ft.
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ElluduStrialComotarcial • E3Rcsidential Wafer Supp1S.(s1rued) - - -..::Itti CRottr:70 ,.741- ....tALi.7. '
FROM . EMPLACOILNT METHOD&Asionn
0 krip.ation . . • 0 'ft. 3 ft,' -Portland ' Pour . - •
-Non-Water Supply Well: . ,. . . .. . . .
R1Monitoring 1:11ieCO.vcrY . ,
Injection Well: ft. rt..
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. IZIAquifcrltdc.hargi ' . . , Citivutklwalcir Reincdialtiou 49.(SA.NDIGRAVELPACK'filipitlic3blOY.;',.. -,"---:-.7.--..-- —
ROM. TO - a:AT:iotal. . • -Itall0ACEAl1iNt METHOD
. . PAtjuiferStOwc and Rceov.4q. EISulinity flirter 4 R. 16 ft. Sand II I #2.
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OAquifer Test ' LlStainiwaterPn4ags
ft.. ft. i.
tit VixiTcntal 1-cfmotpgy IfiSobSidence Condit,i I` • .
,10.'DRILLINGIOGfaitaili idditiOliiil sheets-if iteceisir4
1:ootithemeil("clased Loop} - hltrac:r , FROM ' 10 . DESCRIPTION(cokr.!mob c.11,mill/nick OK.vtin sit...N tee-.)
LIGoothennal(FleatingiCoolitig Return) Elbiher(explain under 421 Retualits) , ft. . ft' 1:
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It. ft. . 1 1 •
.4.:Date Weli(s)coniplefed:.6715-2023 •VriretilD#Htti-2 SR •
it. See Seal'a Noted I
'W .
LII Location: .ft.- ft, t
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Holcomb-Creosote-Site . ' . .I ft.. .ft,- . I ' SEP-1-240N
Facil vo thcr Nam • , Facllity ipm(lfappil7-ab1ci, ,. .
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5016 US Hwy 601, Yadkinville, NC, 27005 , - " . . rt. • ft.. I fftinla'v.c...c1 Prrt:...-..,744g.1;',I
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...:,,,A..- ' ';CV.T,','13
Ilk .'-'".-'•"'''''.F5s,ciLY-.00 Tip . 32 ti REMARKS' .
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Yadkin . . -Bentonite seal from 3-4'1' . - • •
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Cuuoiy . . Pareci idusiaricalion No.(PIN) l','•0:..1.-Olitinic'ailillainginsdn in degrcesitniitutesttetintls air accitiial ticgkes: 2.., certifteatianu '. •
(itu ell 041d,one latiloit is•samiacia) 1
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Chris RUffer. i W 8/20/2023
Signal:on'a f Cc:tilled Well Cc(ameba:- . . - Mk
6.Is(Mk)the'well(s): ISPermanent or OTemporaty
By signiwg).V1 foimj hereby certify 0 the Irefifs)twt.r 04.61v) m:riffled ht.wearrizince
Ira/5.4 NCAC 02C;01(10 or/,54 Aratc!`02 ..Q2013.14'07 eonstmerfon StandaRis(TMxlms:a
7.4 this a rejr'air to an eiistinguolli Milks' or pNo .elikc.oftrik ircOni bits'Iwo pror qrd ra'sho Uri(iiiviier.
If 111(s:Is a repak,fill aim 41701.1.71 li'di MISIM'Clitlf;MVUIVIVriall arid 1.;s•pIa1st the rare of rlie
itipair= 1.ilea!02 Avnarkt si.cling ai-bit the bl:di of Mix forec - ' 23.Site diagram or additional.weiC4iefilits: . .
You may use the back of this page ft3' v.-proideladditioual well site details or well
•8./cumber of Wells couStrueted: 1 • . . • coustniction details. You inns also attach iidditioual pages if occessaly.
For multiple kljecsIou'or oixi-uvarer supply 1$1qP ONLY ieJth(humor.construdiouf you orb - ,. ,
sebniiirt4 form. - - SUBMITTAL ISTSTUCTIONS • '
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.9.Total welt depth Mon-land atitfacet: 16 . Ay :240. Fur Alt WIlsi Submit this form within 30 cloys-of cennpletion of welt
For itruiriplr irrlIslisr all&TWA'ifillfftrt;us(e.sao.rpfr-•3@2t3l7 cud 2e Irs9) ' 'constnidtion to the following: :
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10.Statie.water[del below top of easing.. • , (ft) Division or-Water ReSourceS,Information Processing Unit,
If loam,kid Is Obove&ay.isse;"+" 1617 ALiiI.Seilice(kilter,Raleigh,NC.27691/-I617
11.Borehole diameter:6" . (in.) 24b.For Intectioit'Wells ONLY: ht addition to-sending the font:to the address in.
Ild above.also submit a.copy of ails!form within 30 days of.completion of W011
11.Well truction inethad:Sonic construction to-the foiloWinm•' r :
(Lc.augur,rotary.cal:to:dim:push.etc.}
. . . . • - . • Division of Water itpourct-s,Utiderground Infection Control Prime-ant,
FOR WATER SUPPLY WELLS ONLY:' , - 1636 Mail Service Center,Raleigh,NC 27699-1636
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24e.For'4Vatci"Suunlv&Iniectfort Wells:
113a,Vict(gPm) Method of tat:
' Also sohniit One tOpy of this flint:1Wirthin 30'ijays of comPletion of
13b.Disinfection type: Amount: • well cohitroction to the county heal h depart:nein of the county whom
emstrticted.
Farm GALL North Canaltna Dqanntent.or EMIR:ill/11CW and Natural Rq3+313fCCS:-D4.is Ion ol'Araterftairees -Revised August 2013