GW1--04828_Well Construction - GW1_20240814

,
WELL CONSTRUCTION RECORD For Imoraai Use ONLY:
This form can Lr used for single nr mrdtipk Hells
I.Well Contractor Information:
Ia.WATER ZONES
Chris Ruffer now TO DW_ttRlnu►v
W'dl Contractor Nink
R. II,
•—
ft, ft.
4223-A I
NC Well Contractor Col ification Number • IS.OUTER CASING(for mulls-cased wells)OR LINER(U N[ea
r110%1 TO 1 myytFTFIt THICK Arsti N ATV RtAl
SAEDACCO 0 n. 5 ft. ; 1 is. SCH-40 PVC
1
n,;:n. \; •, I .omit CA31N6 Ott JIBING tgesihenral chew)-liar)
MOWTO DtANf TFR HOICK F\y MATERIAL
2.Well Construction Penult N: R. R.
r',able 14r11 permits(i.e.Counn•..Sian.,Variance.LTartiol err.!
3.Well 1 se Irheck well use): 17.
Wa tor tiopph Wcll. PROM TO DIAN/TTR ? star MU TIICusa n3 Mttl*tAI. ,
Li d I_AgmmItunIMunwipat ublic 5 R. 20 ft. 1 Ia• 010 SCR-40 PVC
❑Geoth renal(Iieating'Cooling Supply l I(Residential Water Supply(sine) R' R' IN.
❑lduslriaLCommcveial I'Residential WaterSupph(shared) I8.G M TO ITT TO
'RO MATE RIA1 [s[PlACiM[VT]ItIrTR00 a AMOUNT
❑kngation ft. R.
Non-Water Supply.Well: R. --•+ -
ICklon nonng ❑Recos'cry -(
Injection Well: rt. ft. '
❑Aquifer Recharge ❑Groundwater Rentcdianion t't.s%s o(.R ss 1.1 P s(I.I if:yq,Iikat tat
Itrt'n In sI I.MRISI. FNPI.st IAA r\T NI"Timft
❑Aquifer Storage and Recovers ❑Salinity Harrier II - it
0 Aquifer Test ❑Stor ms:ter Drainage -
n. rr.
❑E ipcnmcrnal Technology ❑Suhsidcn:c Comm' (.1 ()nit 11st.I.Of,(attach ad.nio iai sheets if aac+elnars)
❑Geothen al(Closed Loop) ❑Tracer Fnost j n► • D►,.n trnn\!osier.ha.a.r..,.mans(,n pi.grans dose.rat.'
❑Geothennal(Heating m tooling Return) ❑Other(explain under 02I Reaiksi R R
ft. ft.
4.Date Wells)Completed: 08/01/2024 viol ion TW-1
R. ft.
5a.Well Location: ft. f4 , .• ,R � f
OTTO HARRIS STORE R. rt. AUGi 1,t,00rrrNa,r. Facility ID#(if applicable) — AU 1 ` 2024
R. R.
999 Hwy 158, GARYSBURG, NC, 27631 R. ft. I I-.:;,:-7.4...' ;►'^^3rvv-:v-.►..kk
Phs steal Address_Cits.ad Zip 21.R![IARIe$ aura,!C.41
NORTHAMPTON Temporary well
Counts Rana:I!acidification No IPIN1
Sb.Latitude and I.nngitnde in dt•Arecslminutcsisecnnds or decimal degrees:
(ifa evil ficld ton tar Sow 1.millitAc, l 22.f ertlficatL►a:
N V. Chris Ruffer 8/1/2024
S.iut,ue of Ccnmied Well Curwatot Dale
6.Is(arc,the wcllts): :.'Permanent or X I eml"iron Ni'toning this form 1 kerriry terrify that the swthXl owe fnrrrr)Llfllartnrr red in accordant
wish F A'1 NCAC 02C.0100 or FM NCAC 02C.0200 Well Caiatntcffoa Saondards told that,.
7.la this a repair! to an existing well: J 1 es or EN,, roar of Ail rrronf halt harm provided to the%ell o r.wne
If Otis am 0 repair.jiff tsar(moan N el."4,7,141 iisO ntforr a 0011 said r s$itt the.Wfar of ow
repair under 021 rear-rf,nation or tin the hest of this form. 23.Site diagram or additional well details:
You ntay use the back of this page to pros ide additional well site details or well
8.Number of welh constructed: 1 constm:-tion details. You may also.Mach additional pages if neeessan.
Fo..nsloplr snie.runt.n owl-wore,doggie writs OA'L)s'rth a,r same run.rrien.wr ,t:a r Inn
Aubrni,ins-form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 20 (ft.) 21a. For All Wells: Stnbnst this funs within 111 Jays of compktwtt of well
for.uvinplr u.11.in;id)depth.ifdifermos t..00lpfe-rr!2no'.oat'4,in(!) constmetinn to the following
Ill.Static water ki el Ixluw'Imp of elalav 15 (ft.) Division of Water Resources.Information Processing I nit.
or !weir)is ours t(ism x.ix "4" 1617 Mail Service('cater,Raleigh,NC 27699-1617
t I.1311rcbole diameter:8.25" Owl 21b.For Inicetioa Welly ONLY: In addition to sending the form to the address in
24a abuse. also submit a copy of this form within k)days of completion of well
12.Well annstrw•tion method:RSA construction to the following.
(r c anger.roan.cable.direct push etc.)
Dhision of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: If36 Mail ties ice Center•Raleigh.NC 27h99-t636
IJa tilddbq►all y oftat 2Je.For WaterSupple &Injection Welk:
Also submit one copy of this fonts isithnl to daysof completion of
IJb.Disinfection type Amount: well constnich coma.,
on to the coty health department of the counts where
commicted
Fenn GW-t North Carolina Depunm nt of Ens.moment and Natural Resources-Do n an of Water Rmotrcm Res iced August S I 1