GW1--05367_Well Construction - GW1_20240909

WELL CONSTRUCTION RECORD For Internal Cie ONLY:
This Form can I.nc used for single oe multiple aclls
1.Well Contractor Information:
II.WATER ZAN[S
Chris Buffer (MOM 1 to OTSI•RI►TION
Weil('oteractor Name It, ft.
4223 A ft. f6
NC Well Contractor Cenifecation Kanter y 13,OUTER CASING(for multi-eased wens)OR LINER(W up Ikahkl
THOM TO DISM►TIR THICKNESS MATT/HSI
SAEDACCO n• n. M.
Co input)Nang ...SINNER!CASING OR TIRING(goal chnd4sian
ROM TO J OUNIETIR THICKNESS M.ITERI.AL
2.Well Construction Permit N: 0 ft. 15 rt. 1 111. SCH-40 PVC
Ln 4d1 appli.obl.•,a ell prrmaa it e.County.M e,Variance.Injecticat or.t , ..
ft. ft. I hi.
3.Well F'se(check well sae): 1 -------
1
Water Snppli Well:
ntoN TO ORMWITR HOT N lI THt(i NTs, MAt'RatAl.
❑Agricultural ❑Municipal;Public 15 ft. 20 A. 1 is 010 SCE-40 PVC
❑Geothermal IHealin .CUoting Supply) n' h g ❑Residentwl Water Supply(stogie)
ti
❑lndustriaLComntcrcial ❑Residential Water Supply(shared) MGM OUg TO MATERIAL EMPIACE MEN T METHOD a AMOUNT
❑hrigation rt. ft.
Non-Water Supply.Well:
rt. ft.
RIMonitonng ❑RexoNrt
injection Well: ft. n.
0 Aquifer charge ❑(imundwaicrRcmcdiaion 19.SANSIGRAVRL PACE l6apailadlit)
!ROM TO MATERRI. l.M PtAtrAIVNTMrtfOD
❑Aquifer Storage and Rccoycn ❑Salinith Hamer ft. ft.
❑Aquifer Test CI Stornww attar Drainage
n, ft.
❑LxpentltclMal Tahnobg y ❑Suhsldcttcc('nlarnl 79.DRILLING LOG(attach additional sheen if accessary)
!JGothennal(Closed Loop ❑Tracer violist TO Di.N('Ntrtlii\ o..r,hraue..,wltncka ye.von.non.eat.)
❑Geothermal iHeatiug/Coolimp Return) ❑Ocher(eNplant under 021 Remarl. R. ft.
ft. n.
4.Date Well(s)Com tiled: 8-15-2024 wdl IDsSDC-17 .-•-• _-.. .� "'° s�
p ft„ See Geg's Notes ` I -T,./..�.,,,,,i...D
`.
Sa.Will Location:
Catsburq Country Store 14 ft.
SEP 4 9 2024
Facilsi,On nor Name Facilih ID#(ifapplrabk)
f1, ft. lnf>.:?t'.&.trtr ?rrryq eit l,kllC
1110 Old Oxford Rd., Durham, NC, 27704 R.-.— VTc;,alf OG 1
Pln steal Address_Cite.and Zip ~ ---—_
:1.REMARKS
Durham Grab groundwater sample via 1" temp well
I,ant Parcel Idandi:ahen N,. !PIN)
5h.Latitude and Longitude in tkgrccsiminatcs/seconds or decimal degrees: 22,('utiicatina:
Of well rk1d,one laalorg 1%sunkkm)
N w Chris Ruffer 8/16/2024
Signatuue of Certified Well C o neas t e r hole
6.Is lire)the Ncllf sl: 'Permanent or g'Tcndg"trap St*ring ahu form,I hereby rernfe Ara the wriNs I tsw(were)ce.armrrred to accordance
sue I SA NCAC OIC.01riO or 154 NCAC(12C.0200 Writ Cosatn-riom Saa+Jar4,WO char a
7.Is this a repair to an ecistiag well: Yea‘ or EN% cool n(d is rr,,rd lrrtt,brew ra,,r,fd rn the sell owner.
11164 ts a repair.fill ma known well,amups,row arf'w orlon and rcpiant the aware of the
repair under I21 remarks ser)i,m tie on rhr hart of this form. 23.Site diagram or additional w ell details:
You may use the buck of this page to provide additional well site details or well
S.Nnmberof wells constructed: 1 construction details. You mac also attach additional pages if uecessan.
for ma/Hine inject.':. ..,ss-aeaer urppls wells ONLY owl,rhr same ctarsa•wTele v,a,-no
submit one term. SI IBMITTAL INSTUCTIONS
9.Taal well depth trt:ktw land surface 20 ((7,) 21a. For All Wells: Submit this farm within lm days of completion of well
For maniple wells Jig as delete rf(PAWN twit w per•b*Ziltr<Ind 2 d'Hari constniction to the following
II.Static water level below top of casing: (ft.) Oh-ision of Water Resources,Information Processing l nit.
if wort,hurl,.ah<wr I nslny.a•, • 1617 Mail Service(eater.Raleigh,NC 27699-1617
IL Borehole diameter:6" (in.) 24h.Fur Injection w'etls ONLY: In addition to sending the form to the address in
14aabose. also submit a cops of this form within z() days of completion of well
12.Well construction method: Sonic commit:bon to the follow tug.
ii c.au cr.roan.cable.direct puck ct,
Dhision of Water Resources.Underground Injection Control Program,
FOR V 1 IE.R SUPPLY WELLS ONLY: 163E M11iii Sees ice Center.Raleigh,NC'27699-1636
13a 1 irid I�pml __ Method of rest:
14e.Fur W titer Supple A.Injection Wells:
Also submit one cops of this form whhm tin dais olconipletion of
IJh_Disinfection ry pc: Amount: well construction to the count heath department of the county where
constructed
Form GW-I Nonh C:mltna[)gtwin eta of Ern tmnasnu and Natural Resources- Holston of wAACr Riairces Revised Angus 2+013