GW1--04891_Well Construction - GW1_20240828

WELL CONSTRUCTION RECORD F
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The form can be used for single or multiple oats ..
I.Well Contractor Information:
It WATRR ZONES
Chris Ruffer MOM II) DRACRIPTiON
Well Contractor Name ft, fl.
ft, ft.
4223A
NC Well Contractor Certification Number 15.OUTER CASING(isr multi-tared trek)OR LINER(Y Reath)
►ROM TO DHi%tVT1R THR'A'FCA MATFRtu
SAEDACCO ft. ft. in.
Company Name U`18041R CASING OR T RING(1,ruthermat closed-ioop)
ROM TO D1tttFTFR TTIK_ANESS NRTTRR.LL
2,Weft CDnrtrijcdnn Permit N: WM0100582 0 It. 45 id. 2 SCH 40 PVC
List all amlit ale o rl1 permits•r r , i a nn'e.lreerlim eh'.r --
ft. ft. in.
3.Well Use(check well tact: 17-SCREEN
WaierSupph Well: FROM TO DI MAT son" TIM kNFO. !I*TFRnat.
❑Agneultural ❑Mtrricipa6'Pubik 45 ft. 1!
It 2 iw .010 SCH 40 l Pvc
❑Geothennat!He ting/Cooling Supply) ❑Residential Water Supply(single) ry {! ii- in.
a
❑htdustriaUCornmercial DResidentwl Water Supply ishared/ 11-aROUT
PROM _TO MATERIALtZHPLICFMENT MEiROO AL AMOUNT
❑hnglttsi n 0 it. 40 ft. Portland Injection
Non-Water Suppi)Well: ft. .
NMonitonng °kecowry —I
[ejection Well: iI. O.
°Aquifer Recharge ❑Groundttatcr Rcnlcdiaiion 19.SANDN.RAVEL PACK(if tytplka►k►
°Aquifer Storage and Recover ❑Salinity Harrier PROM To j St stints!. lNM.arfMr.Nr minion
43 ft. 45 fl, Sand #2
❑Aquifer Test ❑titormwatcr Drainage n. O. —
°Frpctemcatal Technokrin °Subsidets c Control
❑I,eoUretmal(Closed Loop ❑Tracer 2S DRILLING LOG(attach additional sheets if aecessan)
I MOW TO DRA('RIPT1oN ttoVr,loons caw,xri&rmL hpt.pant se'.<tt.l
❑Geothermal(Heating:Cooling Retunrl ❑Other iecplam under N21 Retnaiks) n' R.
ft. ft,
4-Date Welt(s)Completed: 7/17/24 well 1DAMW-4
\•...-\ I, t-- c
Si.Well Location: R. ft.
ft. rt. AUG ? b 2024
PodiaA'Oenet Name Facility iDN(if ipplicablei —
115 W. 1st Street , Rutherfordton, NC, 28139 — fit, rI U/tC,LC-v
P1nsieal Address,Cih.and Zip
ll.RlMARpti
Rutherford 1610812975 Bentonite seal from 40'-43'
i•.•,u I. Parcel Identification No tPt"
ib.Latitude and Longitude in degn'rs/minutesisecnnds or decimal degrees.• 22.(ctyiti-11ion•
(if ucli field.one las1ung as sufficient)
N W Chris Ruffer 8/7/2024
Si,_�, of Ccnhlied Well t:auuaitor WIC
6.Is(are)the%elks): XPermanent or _JTemporat}
fi 3evang lids form,I ktreim err*that the wdlfxi rwtr(weir)rors ruder or accordance'
with 15A NCAC 02C,0100 or 1 SA NCAC 02C,0200 Well Constmrticrn Shrrdrtsdt and river a
7.Is this a repair to an existing well: ❑1'ea or N No ropy of Mir rervmi lawn area provided to,lw moil(Writer.
If rigs::o reptile,fill 14Y/km mmtl well crourff(ion Pti,,r,',N."' !WI/ t'pfaln dw norms(of thr
repair wedrr 121 remarks-xet-Aam or on the hock of this form. 23.Site diagram or adt ditiorat well details:
You wrap use the back of this page to pro%ode additional well site details or well
8.Narnber of wells catnsiructed: 1 construction details. You may also attach additional pages if necessan.
rut.malrrpk wit-,oI'pI or WMI•ucat'r upph wells ONLY wait the somecoaeaWarior.tat twin
xrbmir come form. SI IBMITTAL INSTUCTiONS
9.Total well depth below lard surface: 55 (f1.) 24a. Fur All Wells: Submit this farm within 30 days of complclion of well
For matlrtpir ttOtt lot oil mkprhr r[Jd urea:to eropfe-3Ea200'twool 20 ioin construction to the following
lR.Static water level below top of candor (ft.) Division of Water Resources,Information Processing Unit,
//mare,i. ,l r,.hove(attar ate 1617 Mail Service('enter.Raleigh.NC 2 7699-16 1 7
t I.Borehole diameter:6 (in,) 24b.for injection Weill ONLY: in addition to sending the form to the address to
24a abr.%e. also submit a copy of this form within 10 days of completion of well
12,Well construction method: NSA collsstmctwut to the folioamg_
t i c auger.rotas.cable.direct push.elc.1
Division of Water Resources,Underground Injection Comm,Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh.N( 2'699-1634
13a Yield(lllrrl) Method elf text:
tic.For Water huppla S.Injection Wells:
Also submit one cop) of this form within to &fats of completion of
lib.Disinfection �; well construction to the counts health department of the coolly whet
constructed
Form GW-1 North Carolina Dcprounent of Ea rrotuutiu and Natural Resources-Dia awn of Want Resotrem RCN tied.August lit 11