GW1--05364_Well Construction - GW1_20240909

WELL CONSTRUCTION RECORD For hxrnalUscONLY:
lllts fortis can he oxd fire single or mullipk wells
1.Well Contractor Information:
Ia.W'ATIR ZONES
Chris Ruffer • mine I r0 bV(RtrttON
Well Colones*Name ft, I h.
4223 A n• ft,
NC Welt Conlmelor Ccnifrc.alnn'sinter
j 11.OUTER CASING(for multi-eased etis1 Oft LINERIY Ikaak)
rNo‘l TO ettiMrrtn Till( rsM '4 TTntII
SAEDACCO n' n• O
('aupno sans. 16,INNER CASING OR TUNING tjneIbertaaf cleeddullr) .._
PROM IMASIFTFR IIII(A%r:S1 M.SF[RI II2.Well Canstreetion Permit N: 0 It,Tio
15 ft. 1 In. SCH-40 PVC
LEO all applwoble writ prnruts(Lr.County.State.Variance.Igerrerl ea.t n. ft.
-
911.
3.WdI t-sc(cheek well use►: 17.acity4 -
WaterSupph %.ell: VftOM TO DIAMtTra Mart stir. THI(1(NrIs 1 Iva-n m.
°Agricultural OMunicipcll.Ptsblic 15 ft. 20 ft. 1 MI, 010 SCH-40 PVC
h' h isOGeothetmal lHealing oolin Supply) OResidcntial Water Supply(� 1r,
❑Industrial Commercial °Residential Water Supply(slelmd 1 IIa01h1 TO MATERIAL EMPLACEMENT M£tAOO t AMOCYT
DImgation h, h,
Non-Wafer Supply.Well:
n. ft.
110Morlitonn6 ❑Recovery ._ ,
Injection WdI: II. n.
LlAquifcr Recharge LlGmtindwalcr Rem:dialion 1s.SAND(.ILIA t:LPACK(YaoulkeMt)
141151 10 evnitat41. YMr1.u-tMr\T METHOD
CIAquifcr Storage and Recovery ❑Salinity.Barrier R. h.
❑Aquifer Test ❑Stomrw:ter Drainage h, h.
❑Eylcnmrntal Tn hrHsbRl ❑Suhstdlcrcc Control 211,DRil l I'G LOG latlacll additional Moro if ocecisan I
❑Geothermal iClosed Loop' ❑Tracct FROM TO OFscRlrnnv.ter.L11MIM.,.vdr'I,ML I+pf,grab taa,eaca
❑Geoihenual IHeaung!C u,'ltii.Helton) ❑Other(esplaln under#21 Remarks) h. ft.
h. h. e'^ -- _
4.Date Weals)Completed: 8-14-2024 %%a ID.SDC-10 • - :Y i'�r'+
1 h See Gt1fg's Notes I % `p L.; L.)
.a.Wdl Location:
h. f.
Catsburg Country Store h h S E P Si 9 2024
F«1I,I,OwneWMaim Factlih IDStifapplicabe1 h. II,/to.lArawt-+i: ,•'rYr somwrip Unit
1110 Old Oxford Rd., Durham, NC, 27704 h. ft. NolL'Cil"i::C
Pin st:ai Address.Cits.and Zp 2l.RIMARK5 - -
Durham Grab groundwater sample via 1" temp well
(nun,' tsercclIdenldcvintiNo 1 PIN 1
Sb,Latitude and l.on)litwdc in degrees/minutes/seconds or decimal degrees: 22.(irdRcattba:
III aell kld,lvw 1aLTogg Is wllit:iced)
N W Chris Ruffer 8/16/2024
Simone of Certified Well Contractor Cline
6.Ls rare)the nettle): DPermantm or X'I i'ntlNtra ry Us ogling leis for ,.I hrrrhr certify rhea rho we/Nit WW1 IWrrr1 tvwasinwied to areMlim.e
With 1 5.4 NCAC 02C.O100 or 154 NCAC 02C.112t'io Well C'Irnsow,non Snowdards and rhos,l
7.Is this a repair to as existing wen: J Y es or ENO r.er+of rhi,rr,nnl has he.,pro,1,1 li rn the wr!!owner
If Otis U N trpoor,6N 1Ntt IlOWNO Weil,rNUNrn 10,01 iWkw,,4HNra 11141 r tp1W0 the water of cur
repair alder 021 malaria section or on the hark of this tarn,. 23.Site diagram or additiunal*ell details:
You may use the back of this{rage to pros ide additional well site details or well
E.Number of wells constructed: 1 :otnttucliondetails. You nos also attach additional pages if trecessan.
for mainplo l'tk,mul,f Han-Wafer lappls 11,111 ONLY teak the dale t.Mseriertion ,era 1 T1
aaballf o.w feral. SUBMITTAL INSTUCTIONS
9.Total well depth below lard surfaces 20 (ft.) 14s. For All Wells: Submit this fort uuthm MI days of completion of well
Foe ntalsipk.olls list(di depths if different tekaniple-.00^.204I and 20:100 consrnictionto the following
10.Static water level below top or rasing: (rt.) Division of Water Resources.Information Processing(nit.
If Huey 7r,r7 n irhoer,aim;.n•• . 1617 Mail Service('cater.Raleigh,NC 27699-16t7
I I.Borehole diameter:6" Da.) 246.For Inked.**Welb ONLY: In addition to sending the form to the address in
24aaboye. also submit a copy of this form within tO dais of completion of well
12,Well eotlstrattior imbed:Sonic cotnutuiion to the following.
tie.auger.rocs',cable,direct push.etc.)
Division of Water Resources.Underground Injection Control Program.
FOR WATER SUPPLY WELLS ONLY: 163A Mail Sen ice Center.Raleigh.VC 27699.1636
13a Yield IL'P1iil I 24e.rue R tier Supply A.Injection Wells:
Also submit one cops of this funs wilhm to dot s of completion of
1311_Disinfection n pee Amount: __ well construction to the countshealth department of the county where
eonsmtcted
FonsGW-1 Non ('aroluta D+Tunnwru of Em imminent amid Natural Resources-Division of Water Resotrcm Ho tied August 2.111 4