GW1--05365_Well Construction - GW1_20240909

WELL CONSTRUCTION RECORD For lnternal Use ONLY:
This form can(v raved for ink or nndttpk Isclls
I.Well Contractor Information:
Chris Buffer FROM To DEM•RtPt ION
Well Contra:tot Name R. ft.
4223 A ft. R.
NC Well Contractor Ccnifrcalion orrice ' IS.OUTER CASING(for mel F ased wells)OR LINER(if applka►kf
room I To owurrrR rtuctoVSS l S1SttRtio
SAEDACCO ft. rt. is. JI
Congas:*Name 1 16.INNER('ASIN(:OR TUBING ligialinnimal etched-leep)
FRl)NI to : DtiMETER nutisiss si kTF NI kI
2,'Weil CDtltRI!•Ctlnq Permit N 0 II. 10 ft. 1 in- SCH-40 PVC
Liu all applicable art permits(Le.County.,State,Variance,IrpxDat ear., '--- }I--
0. fl- I in.
3.Well Use(check well me) `1-.S(BEEN f
Water Supply Well: VOII' , To , DtAMP /r n
Tra _MOT _i MATERIAL.
OAgrwulpnal °Municipal+Arblic 10 R. 25 ft. 1 in. .010 SCH-40 PVC
CGeothetmal(Heating/Cooling S y) °Residential Water Supply(single) R ft. OIL
❑Industrial/Commercial °Residential Water Supply(shored) 1 ttul j TO I MATERIAL E1trtACE I1.T avferNOD A AMOUNT
'
❑kngation a. ft
Non-Water Supply Well: r -, --1
®Monitonne ❑Recover �__., —_ — i
lujerthln Well: ft. ft.
0 Agui1cr Recharge °Groundwater Rcmcdiaion 19,SANDK:RAYRL PACIC(lf llppBeeYf)
PROM rm MATPRLiI. FmW ACENITNI MrTlttan
°Aquifer Storage and Recot'ety ❑Salinity Hamer ft, 4.
CI Aquifer Test ❑S(ormx:to Drainiee --
fl, - ft.
°Expenmemal tRhnolol•y. ❑Satrsidcrtcc Control 211.ORD.LING LOG(attach adiNtleaai sines if uecearanl
❑Geothennal(C•losed Loops (]Tracer ntos To , DBSCRt►TION rtol.r.►ardww,t.,it L l,Mr,v.ile rn•,or.i
DGeothennal(HcanntCuoline Return) °O(her(explain under S2II Renfadis) R, n.
ft. ft.
4.Date Well(s0 Completed: 8-14-2024 Wdl in.SDC-14 a
ft. See Grin's Notes I t 'l- i r
Sa Well Location: R ft. `�p�u�- V a L.'
Catsburg Country Store ft. ft. S E r V 9 ZQ24
Facibn OtrcrNang Facility Hhil(if applicable)
ft. ft.
if.fv:7'laiLs,r::nary srra'.'
1110 Old Oxford Rd., Durham, NC, 27704 ft ft err • y V
Physical Address City-and Zip r 21.aLMARIC.x
Durham Grab groundwater sample via 1" temp well
Carta) l':ui x]Id.ui,rlcati,n No WIN i
ib.Latitude and Longitude in deg eeelminutcsiseeondsor decimal degrees: 22.('cniticatioa:
Elfwcil field,one latlu f isstdlickat1
Chris Ruffer 8/16/2024
Signature of Certified Well Contractor Dotc
6.is(are)the wellls): ❑Permanent ur EKTemperan
fty signing whir form.1 keit*cerry'y dug the%WO(tau Creme)certrntared or acronia cr
with 154 NCAC 02C.0100 or 154 NCAC 02C.0200 We0 Constnwncw Standards and Aar a
7.Is this a repair to an existing well: °Yes er EN* ropy a(chi rr.'orj farts Items pr vnted to Me aril moire,
ff tots is a lepuir,fit ma known 1,41,nwt,tw rtr n mforrraurirat and r.tpkaut rhea curare of rhr
repair ander t21«wrarks srtli as or on the bark of this farm. 23.Site diagram or additional well details:
You mar use the back of this page to preside additional well site details or well
8.Number of wells eotlslrreted: 1 construction details. You inay also attach additional pages if necessary.
For nwhipte Akerson or sett-Naar sxppfr wets ONLY wail day sore rrttfSent(tun t„w,art
salmi!are form. Si IBN11TTAl,INSTUCTIIONS
9.Total well depth below load surface 15 ((y,) 24m For All Wells Submit Ibis limn wuhln 111 d:nsof completion of well
For mairiple wefts list all*pens ha rt„a(crantpk•-t�ZOlr.,,41 r,t 119;s constnictton to the following-
10.Static water level below top of easing: (ft.) Division of Water Resources,Information Processing I nit.
if wake true r.gbr.sr r asv+r O.F. • 1617 Mail Service Center,Raleigh,NC 27699-1617
U.Borehole diameter:6" (fa l 24b.For!election Welk ONLY: In addition to sending the form to the address in
24aabove. also subunit a copy of this form within tO days of completion of well
12.Well construction method: Sonic cortslrta-tion to the following.
ii c.auger.rota:..cable.direct punk etc I
Division of Water Resources.Underground injection Control Program.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Set-.ice Center.Raleigh.N('27699-1636
12a.Yield(((pot) Method of test:------- 21c.For Water Nupph S.Injrr'lion Wells:
_.- Also submit our cops of this Finn nr ileum Sit dos s of completion of
well conslnlction to the county- health de county where
of the coun where
I ih-Disinfection type: Amount:
constructed
Fenn GW-I North Carolina E)cp mntcnr of Ern trolme/li aril Natural Resources-Memo of Water Reotr(r Res Iscd August?ir 1?