GW1--04890_Well Construction - GW1_20240828

WELL CONSTRUCTION RECORD For Internal Use ONLY.
This form can be used for singk or multiple%ells
I.Well Contractor Information:
14.WA13R ZONRS
Chris Buffer FNOM 1O DttS('RlttiON
',\.it i :a rr:loot Name rt. ft.
rt, ft.
4223A
NC Well Coin r mop Certification Number 1S.OUTER CASING(Fps aeNl-card"mkt OR LINER(U al Inaba)
FROM TO DtAMFTFR TRICK NUM M.ATFRt4I
SAEDACCO ft. ft. in.
(oasput)eons: lik.smut CASING OR 1 I Lclosed-NovING(geutbenaai closed-NovFROM TO DtiMFTFR TO11('A'FSS M%1TRIM
2,Well Conittritctioa Per'adt#: W40100581 0 R. 45 I). 2 w• SCH 40 PVC
Liu all applicable well pennils O-r.County.Sher.Variance.Mierflan etr.1 -- - -—
f. (I. is.
3.Well[ire(check:well see): 17. Q1
Wafer Supply Well: FROM 10 , DIAMPTFR MOTS l! Tttt(1COSS. M4TFRlAl.
❑Agricul Ural ❑MtmicipaL'Public 45 p• 55 p• 2 ill. 010 SCH 40 PVC
ti rt. in.
OGeothemral(Reating/C'ooling Supply) ❑Residential Water Supply(single)
0Industrial/Commercial OResidentwl Water Supply(shared) la GROUT
FROM TO MATERt4t. EMPLACEMENT METHOD a AMOUNT,
0
❑ltrigatron 0 ft. 40 ft. Portland Injection
Non-Water Supply Well: p rt. --• —I
ISIMonilonng ❑Recovery
injection Well: h. ft.
❑Aquifer Recharge ❑Groundwater Rcnbedianon ts.SAND/GRAVEL PACK Of npalimbie)
FROM 1() MATFRIAI, FMP1At-E IN1miTHon
❑Aquifer Storage and Recrncn ❑Salinity Barrier 43 ft. 45 it. Sand #2
❑Aquifer Test ❑Stormwatcr Drainage
—
ft. ft,
❑Frpcnmcntal Technology ❑Snbsickrce Control
Ia.DRILLING LOG(attach addition'sheets if accecsan)
❑Geothennal(Closed Loupt ❑Tracet rnom To DrrCRIITioN rtot.r,w■rlisew,,oWrnyk o pr,rata woe.eat.I
❑Geodkmsal lIeamne•Coolilie Return( ❑Other(explain under 0021 Remarks) rt. ft.
rt. ft.
#.Date Welk')Completed: 7/17/24 Wdk TDaMW-3 v •
rt. n. ,
Sa.Well Location: ` ' 3_ j"-
h. n.
a. ft AUG 2 b 2024
Facility.Omer Millie Factlrh 1Dit(if applicable> ......_.__ ,
R. u' 1r,`^.:.,,.. - • •
115 W. 1st Street , Rutherfordton, NC, 28139 R. f,. D;.Y..
Plssical Address.CM.and Zip M.REMARKS
Rutherford 1610811957 Bentonite seal from 40'-43'
t.,a i, parcel Ideinht tii,n No I PINn
Sb.Latitude and Longitude in tkgr(•csiminutcs.,seconds or decimal decree : 22.Certification:
(a%sell field.one lttlong is suflicicw>
N W Chris Ruffer 8/7/2024
Signature ofCertified Well Contactor -. ..._ ...._.._. Wit:
ft.blare)the trellis): RPennanem ur IfTemporary Sy a,gning this form,I hereby certify.•shut the tall()teas(weer)corartrwa•red in arrotrraoce
with 15.4 NCAC 02C,0100 or 1 SA NCAC 02C,0200 Well Commerical Standards and that a
7.IN this a repair to an exiMieg well: JYcs or IR No ropy of refit resvrni)sat been prm'ided to tier well owner.
If lie..,,..;'ti..., fill erut known well f cmnnrrlrata sit;.",Hi(sh*dNd a rplaot dtt•uw,reire of the
repair fowler/21 remarks section or on Mr bark of this farm. 23.Site diagram or additional well details:
You eras use the back of this page to prostde additional well site details or well
8.Number of wells constructed: 1 construction details. You tea)'also.attach additional pages if necessary.
for multiple tnnrrton t„rowl-.offer aafpplr wells ONLY wash the NSW CONAItrcNes,ymu awn
submit one faun, SiIBMITTAL INSTUCTIONS
9.Total well depth below land surface 55 off,) 24a. For All Wells: Submit this form within 30 days of compktion of well
For multiple t.elts list tt11 depths ifdrfk'resu(crawly-?1a200'and 28'lOfTt constmctton to the following
10.Stark water level below tip of rashly (ft.) Division of Water Resources,Information Processing Unit.
if wer,level is tit n•e fusing.one"a.. 1617 Mail Service('eater.Raleigh,NC 27699-1617
II.Derekek diameter:6 Da.) 24b.For Ink:lion Welts ONLY: in addition to sending the form to the address on
24aabove. also submit a copy of this form within 30 days of completion of well
12.Well construction method: NSA construction to the following.
i i c.auger.roan.cable.direct push.ere
Dh'kslon of Water Resources.Underground Injection Control Program.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Sen-lee Center.Raleigh.NC 27699-1636
13a Yield(gpm) Method at flat: 24c.For Water Sopplr &Injection Wells:
Also submit one cops of this form ssithm 10 days of completion of
13b.Disinfection tspe: _. Amount: — well construction to the counts health department of the county where
constructed
i ,,,I '.s-i Noah Catalina fkpanrneru of Ern nonneiu and Natural Resolnees-On non of Water Resarcm Rev tsed August 2011