GW1--05368_Well Construction - GW1_20240909

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can he used foe single<i inulttpk.tells
1.Well Contractor Information:
Chris Ruffer I�MA
PROM TO DRSCR t trt1O
ROOS
Well Cranes,ham: fL R.
4223 A ft, D.
NC Well Coraracior Certification Number 15.OUTER CASING Slur small tarot wclh�OR LINER Of alr�licabk)
IRON TO m;MrTrR TRUTiNTSS MMTTNl l
SAEDACCO rt. n' at.
('o1I sue N.utr N.iNNIIR CASING OR TIRING ifatarhermal closed-Wort
TROM TO DI MT TER iIlICKNESS MATERIAL
2.Well Construction Permit#: 0 R. 15 ft. 1 io. SCH-40 PVC
Lau all applirnhle nen prninta it,.County.ShrM,Variance.litection ea-.) ---- - ---,
ft.' ft. in.
Cie(cheek well rsel: 17.SCREEN
Water Supply Well: FROM I TO DIAMETER SIM-sin nit tO f is MAtTr*leL ,
I_iAgncuhutal ['Municipal+Ftiblic 15 R. 20 ft. 1 its .010 SCH-40 PVC
I IGeothennal(HeatingCooling Supply) ❑Residetaial Water Supply tst1,•••' , It. n' 1~
11IndustriatComntercial ['Residential Water Supply
(shared ttWM TO MATERIAL EMPLACEMENT ME TNOD A AMOUNT
❑Impation R. ft.
Non-Water Supply Well: i
n. ' ft.
RMonitoring ❑Rccover ,
lrjection Well: n rr.
❑Aquifer Recharge ❑Groundwaicr Remediation I.,.S t N D t,R.%s l.t.r►(Is i if ttcllatlk)
',iciati . 1U----- MAt'RRtal. WMW.NCEM FM'METROD
❑Aquifer Storage aid Rceoccrs ❑Salinity Barrier ft, ft. —
❑Aquifer Test °Stormw:act Drainage fit. ft.
❑Espcnmemal Tcehnolo(,>t ❑Sdtsidcrcc Control _
20,DRILLING LOG l attach additional shed,if a,eCNsan I
❑Geothemutl(Closed Loop) ['Tracer FROM TO DESCRIPTION,,,.6r,hardNr..,mattock npr.^rain fa, 1
OGeotlennal(Hcatnig+Cooling Return) ['Other(espial,(under 021 Remml h' R'
tt, n.
Date Wrll(sl Completed: 8-13-2024 11d1 1DitSDC-6 I *„ M
1. IL See Goo'E Notes r.#i''; -..-.1.....
p
Vre
5a.Well Location: R ft. Sit Sri , tt )
Catsburg Country Store R. R. SEP o 9 224
Facthits-OrsnetName Facility IDS(if atpplicable) L. D•1 R. ' tl
1110 Old Oxford Rd., Durham, NC, 27704 R. re. Internta.r,: ' -.ry a5q,-0 (�,,y
PM soul addtcstCi,_andZip t 2i.Ku"Aims
.iY`J
Durham Grab groundwater sample via 1" temp well
(•,.it0 Parcel k4ntili(lint,N., IPl\n
th.Latitude and longitude in thgrees.'minutes/aecondsor dreimal degrees: 2,,('erdricatioR:
pi Nclt field.olt Ira tolsg is stdth:k itt
N W Chris Ruffer 8/16/2024
Signature of Certified Well Contractor Dole
i..is(are)the Nell(s): ..1Permanenl or HlTeniperan
Br Asmara:chic firlrn•!hrrchy rer71)'y'ha rho N'lldf!')NLY(Wert',[YntYlN!'Icd in aCY'artfnrl,Y'
usA 1 t4 NCAC 02C.0100 or I SA NCAC 02C.0100 Well Cra urra,0<ar St andarA*and that a
7.Is this a repair to an existing well: DYes or 10 Ne arms n(rhit re nnl has hero provided to the Nyll owner.
If this is a repair,fill tour ono vi aril<.aa,tnn iSa,information an.1 rtplrarn the aurare of rho
r.rlkiir u der/121 remark..Archon or on rho hart of this form. 23.Site diagram or additional Nell details:
1 ott nwy use the back of tilts peter to pros i(k additional tt ell site details or well
S.Number of welh constructed: 1 construction details. You tom also altaclt additional pages if isceessar,
For maltrplr jar,,roe,a n.xn-water supph wells ONLY ovaii the tome cu tsrencus .<w<m,
.ahmar<ate PM,. SUBMITTAL INSTIICTIONS
9.Total well depth below lard surface. 20 (fl.) 21a. For All Wells: Submit this form within 10 days of completion of nett
For maltipk wells list isO,kprh,440:rem°ie.am,pk•t(i 2t5)'and 20 lial'i construction to the followimi
10.Stank water level below top of easlnv (ft.) Division of Water Resources,Information Processing l nit.
h.ta,r.,r.rl It,rhoi t.,osv,y.OW'+ 1617 Mail Service('cater,Raleigh,NC 27699-1617
I I.Borehole diameter:6" (ia.) 2-lb.for Injection W'elb ONLY: In addition to sending the form to the address in
24aabuse. also submit a copy of this form within h)days of completion of well
12.Well(Destruction method:Sonic cons ruction to the following.
tI C anger.roan.cable.direct push.de.l
Division of Water Resources.Underground Injection Control Program,
FOR W 1 TER SUPPLY WELLS ONI 1: 1636 Mail Service Center.Raleigh.N( 276'►'t-1is36
l3:t.Field Igpml _ 11rth,u t of nest:
24e.For Water Soppls A.Inj.rlion Wells:
Also submit otw cop, of this folio %,ithin ;10 doss of completion of
131s.Disinfection qpc Amount: well cansmution to the counts health department of the counts is here
constructed
Form CAC-1 Nonk Carolina LA1xtnNroi,.l his tronarnt and\aulral R.sameces-Divaioa of Water Reotroc RCN Iset1 August Nil?