GW1--02460_Well Construction - GW1_20240423

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: . • WELL CONSTRUCTION RECORD
• This Fain can be used fur single Or multiple%wits .- - \.)\,7\ Far[Manua Use.ONLY:
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16 WietiC.Ontractor.Infortnation: •
...LC-WATER ZONES . - . . •
Chris Ruffer .. . Fowl to ' ov.sottrirtox- • • • I .
wen Contractor Name • ft.. ft,. I I
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4223A . . . . . . L . .• ..
NC Well Contract:a Ccitification Niurher . ,.t3..OUTER CASING-(fefirtutti-eariedisnills)OR-LINER Min tleablel., . . ..
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FROM 70 , ' • OVAMETER. 711ICKNESS, MATERIAL
.SAEDACCO ' . . IL, ,ft.- , in.-
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Clungany Name . . , • . . 16:.1NNER CASING OR TUBING( m ceoilteral dosed-loop)
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. FROM 70 DIAMETER _. IMICKNESS _MATERIAL • '.2.Wc1E.ConStruction Ocrtait 4: , . •
. . - . • ' 0. R. 19 '.. ft, 2" - 4!..• •SCH-4 0 PVC • .
/47411aptlicalle urn pcimits(ix.Countx.Stinil,Arprintrce..filecdcarir.t . -,.. .. - i .•
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3.Weitirse(check Well use)t• . - ' • . 17,SCREEN . ' •
' Water Supply Well: • .. ----•' - . • mom.- , TO . .DIAMF.71R -SLOT SIZE 111!CNN Kiti. 1 57ATERIA I,.
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19 .It. 29 ft 2" ht. '.010 SCH-40 PVC . •
ClAgticultittal .1:1Municipahrublic. . . '
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OCreothemtal Ricating,'Cooling Supply) : 1:IResideutial Water Supply(single) • . . . ft . in , -{ . .
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' . ElludustrialiContmeteial
• • ClRestdentiat Water Su"(sha:'ud) .FR18;OGN1Ra.131: 70 MATER/AL ,'- EMPLACEMEN E METHOD&AMOUNT
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Elfrrigation " ''. • , . O. •' ft. 12 ft,- Portland i. . pumped . . ' ' ' . ., • . .
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. • Nan-Water SupplY WeR:: ' ' . . .
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Riltonhoring , ' . • . PFtecoyciy- , . . '
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•Injecilon Well: • . • .• -ft. ft • - , •
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• E3AqUifer Recharge . bOroutidwater RentediatiOn-• • 21.9:"SAND/GRAVELPACK(if applicaLW
• mewl - . TO- - • NIATRRIAI. .; RSIPI A emskyr sit:mon '
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InAiptifor Storage and qccoycfy • 1.-3 .11ipity Barrio' ' . ' 17 ft.. 30 ft, Sand #2 . .
. . - ID Aquifer Test • . : 135h:twitter Draiiiage• • • -• ' '' . .
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- - - 13B*critticntal Technology • Ei$absidcmc control. • • • .
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. .211.'DRILLiNG'LOG(attach additionialubeets-iineeessaryl •
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CIGeodiennal"Closed Loop) • • . LITracer . FROM- 10 . DF.SCIUPTION Kobe.bardnem,suil'ottkhrat.:0141 Nite.cle.1 .
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• Pavtheitual(Heating:tooling Return) .130ther(etplaiit under#21 Re:narks) ... •r!- . ' . .
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4.Bate WeU(s)Completed: 1/23/2024 .welt mgmw-ft12 8 '. •
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, • , tr, See Gero.'3 Notes -•
. • • 5a.Well Location: . • .11. . ft.,. 1.,;:-,.t;,....-i-.7 1, .."...,"'1....-;
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Cheraours . . . '.. . ft. fl.- ' , APR 2- 2074 . . . . •
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FacilitytOWnerNamo • Facility lit.','(ii-applicablc) • . . .. .
R. ft, ' . .
' Shaw.Hwy.',.Rocky Point NC, 28457 . . , . .
Al. • . -ft,.•
. .• . Plkisical.Aiiiiress.civ.and.ZiP•
11.111110ARICIS ' ' • ' '• •• - • .rA,,vc.,,,,,,-,•;-1_ . .
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Pender. „ . • Beritonite seal from 12-17' :
CoutitY Parcel Identification No,(PIN) . .
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• 511.11..nfitiide and I.Ongitutie in dcgrcestminutiitscconOsT•dc'citital degrees: - 22.Ceitilleation:
(if%1011 Odd,one tat/long B uldfickii1)• • . • . i. . .
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• N • • W Chris- .Ruffee. . . 1/23/2024
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Sigptora a f Cettified Well contractor• .: . - ' Doe • '. . . . . .
• 6.Is(are)the well(s): 10Permartent. .at pTe.tnporary -:
lii.ligniiyg Mir farm-I!tetchy anti&that Jim ivilifki was(mrirl canytructed in nevartiancr
• ivith 1511 NCAC OW.0100 or 154,NCACO2C 0200 Wel(Constmedan Standards and ilwr a
7,Is this a repair,Cu=existing well: oYs or ENo • copy of this woof llaS Ncoprovided rolki;ITU owner.
Uti.74-is a repaly.111 out kceitin well eciantnedon 11(2'97w:ion and erplatn Me narare of the
rrlwir(auto.#21 icintarks irtnient.air an thebrack of thii form. • ' ' 23.Site diatom%or additional well details:" ,•, •.. . ' .
• You may use the back of this page to.provide additionat.well she detail's or Well • .
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8.Number of wells Coustreicterl: 1 • •• . • Coffin:when details. You ivay also attack additional pages if necesSary. • .
For.nuilIplc iojecilon or flOn-nurer supply leas cos ONLY wIrfi die Saltitstruktion,yoli con - . • ..
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=twit'title form. - SUBMITTAL INSTUCTIONS. . .
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9.Total well.depth below land surface: 29 • • . (ft) Zia, Fir All Well..r Submit this form within 30 days of completion of welt
. For maple wells/is,a/depths lf dp rent(v.vtunpre-30200`nig 2€'100), • : constniction to the fottowing: ' ! . -
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10.Static water level below top of casing: . 010 Division at Water RomUrces,Information PrOcessing Unit,
iflvtito tevel is above osing;ase."+" • - 1617 AlaiiServiee Centel',Raleigh,NC 2769!;)16 17
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11,Borehole diameter:6" .(in.) 24b.For Infection Welch ONLY: In addition to sending the form to the address in
24a above.also submit a copy of titisf form within 30 days of completion of well
12.Well Oanstruction'urea:0dt Sonic - construction to the following:•
• lic.auger.'Wary.Cable,direct rink etc.)•
. . ' -DEVISIO It of Water Resources,Undergound Injection control Program;
• , FOR WATER SUPPLY WELES ONLY: • 1636 Mail Service Ceiiter.Raleigh,NC 27699-1636
24e.For Water Supply;Si Injection Welts:
• 13a,Weld Wu) . Method of tcst:
Also-subtilit one copy-of this ihmi Within 30,days Of&unpletion of •
13h.Disinfection type: . Amount: . . well construction io the calmly henithidepOrtment of the.counly Where
constnicted.
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Fa=GW-t .• North Carolina D,Tartuwitt of Einift11411elli and NaturalBesonnees-Division of Wata-Routco .Riviced August-2013