GW1--06125_Well Construction - GW1_20241014

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WELL CONS TRUttICIN•RECORb Int
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For ernid Ifse ONLY:. . .
This form can be used for ititgle or moltiple veils'
1.Well Contractor Information: I .
lttmumatzoNEs
- Chris Buffer. . . . ' FROM 10 DMICItIMIONI • . . .
Well Cortitactot,Nante. ft,
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4223A • ft.-
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NC Well CorarnitarCettifidation Waiter- . • 15-.'OUTEft CASING(fortiohkariedluills)OR LINER trait Wahl&
• • IttiOt TM '-,' • DIAMETER:. - IMICKNESS• ' IV/Alttil'AL• ,
. • SiEDACCO . .. •
. . ,ft,... • , ,I it.L
- CompunyName: • 16.INNER CASING OR TUBING won't:rural dosed400p) •
• ' -FROM 10• DIAMETER THICKNESS MATERIAL -. ,•
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., . 2.,Welltonmpticrion polutt-#4,wm0100581 ; •,; ; • ; •; ; 0 . It. 90 - .ft: 2 . !'Elt; 1 SCE 48 ' •PVC .
Lig all ap•iiiticaNe welfpennit-4.fi,g.Camay.Stra,Varkurce.Infectiot ea).
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IL: -
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• 3,Well Use(chock Weil Use); - • I7 SCREEN
- Water Supply Well:. •: - .- . . . -. . - . ruosi.; . TO - utastrreit st,or w.f.. tittocurser. I Mrlail41.• •
. 40 -ft. 55 'ft; 2 • •in• ' 010 sea 40 - PVC
' ClAgricuittual . Oliitittleip.iiiNblie , .
OGeothomal(Ileatingtuotiag Supply). I:Residential Water SUpply(single) • .ft' "
•-18;cftoUT• .
ClindusftiaKoluntelCial CIResidential Water Supply(shared) • . .-
FROST TO - - -MATERIAL.-, • ENIPIACENIEIT NIMROD&AMOUNT
ElitiiPation . • . . 0 ft
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. . . 35 •ft. Portland Injection
ft
t..Nou-Water&Opt*Well:,: : • : . ' ' : .
• ... • ft.- . • . • ' - ,. 0...tonito. film; . :.
_ -.PRCCOmW . . • ' . .
Injection Welt:- . . . . . . ; ;II.; . •; ft. _ I ; .
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ClAgniterRcchargt ElUirotindisiterftcittediatiOn" - :49.SANIUGHAvEL.PACKrif aliplleatiteT . .. . . .
•-.• .... . . . -wROM-- ' To• - .•i' :WATERT%I; • • ' - 'ESIPLACIAD:NT MrtI1011
EIAMtiferStontge.and l*ovetk IJSalirdly llarrict. 38 ft.. 55 ft. Sand i: #2.
DArprifer Test 13Siountiatcr thainage-
• . . 'ft. • . 'ft.-
• ClEVerimental Technology; . • ElSubsidentO Control • -- - • - •
• "16.--DRELLECD LOG(aitaeltudditionitl`sheel s If occessarrl - -
EICretnItCmtal(Clokt1 Loop): :. It1Tracer- - : '.vrtost' -to DESCRIPTION(cob r.hardnm,tolEnick Dtte.grsitt Nits MO -
ElGtusthermal(lleatino/Crioling Return) :•ClOther(explain wider Ail Remarks) .; 'it-•• . k' .
• . .- ft.-: ; ; ; ft. •, I-. • • -
4.Date Wed(s)Completed:-7/17/24. - ,Mtki1totew-3. • , .
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--..... .t* . !' . pli; '_...,.i . , .;... p,..:,,.i
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Sa;Will Lireation: : :ft. . ft. ; "
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Service Cleaners • : ft.: , : ft; ,
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_ OCT 1 "4 2024
racility/OinurNanig. • Theilhy ibyftrapplkable) • . . ..
115 W. 1st Street , Rutherfordton, NC 28139 ' Inf.7:•:-.-.".•.1 7,-1 '"
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D''',e.i.;;;CI.I'..2 ' • '
. . . P11,ii;iical Address irit.and Zip- :In.REmmus. . _ : . •
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Rutherford '- 1610811,957 Bentonite seal from 35-38'. ' •
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Condi), . . Ixateid tilemificanon No,(PI)1)
5h,I.atitii de and Longitude in'dgmtr_sintinutcstseconds or decimal degrees'
22.Ccrtilleatiotr: .
prliell field,ondlafflouk bl$officksg) - ,'
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Chris Ruffer , 8/7/2024
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Sigoalom;of.C.egificd WgIt Cola-octal'L -• . •. .Dale
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6.1s(are)the wcU(S):.ZIPermanent .or DITemporary.
:Hy signing this frInrr...'1 frereigyerrtiy Mar the,Trellfs)MY(were)Lyangnicsed kr aceordEner
' • . iVith FM P1C4C 02C,proa or ISA NCrte.,02e.400 Well Construetior Standards and rhai d
7.Is thb a repair to aireiisting well: OYes or No :Irt-Viirr.f Mk record hos Ncir-proyiefedte rliil IT11 rnejier.
eiptsis a irpak:fiil oat kwiai well(+monk:I(an Infartnathin and died!'the aware of the
repair rardorP2.I:reniruks,:irriiriii or rm Me bail of ilia farm. . : . .23,Site"diagrant4tr additional well details: . • . .. ,
nth Y-ou ma Use the back of this page to provide additional well site details Lor Well
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S.Nuerof wells Conflicted: 1 . . . construction details. You may also attach additional Page's if iiecesSaty: • .
For multiple(*ohm or nori-irater silpp!,i'welk ONLY Will Ow mate eauritriretion,yak MO . - : • . . • -„•• .
sukurifoarr jam . ,. . . - SUBMITTAL INSTUCTIONS.; ;
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• 9.Total well.depth below land surfaces 5.8 - • - - • - (ft.) .24a,.E-nr All Wells t Submit this!Thrill within 30 daits.of'cosipletion of will
Fiar.nralliplei,;•etls list all depths ildiffer'eo(exarn,Ore-3@200'and 20109) COn5Inictipn to the foltoning: •
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10.Static water level below top of easing:- . .; (fr.) Division of'Water kesourcrtt,Infonitatiot4rucessing Unit,
'heater level Ls above casing;rase"+" ' ' • • - 1617:MailServiee Center,Raleigh,NC 27899-1817
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• it.Borehole diaineter18•25" - lin.li 2.1h.Foritilicetiort'Wells ONLY: in:addition to sending the Omit°the address in
240 aboYe.463 submit a-copy of ibis Ann within 30 days of completion of well
12;Well eronstivction:methodi HSA coilstnietion to the following:
(i.e p.uger:ifotai).daplO dirFct pink CF.:y : • • .. i
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' - • . 'Division of Water Ream'rees,";;tindery-mud Injection Control Porgranr,
FOR WATER SUPPLY WELLS"ONLY: - -1636 Mali Senlee Center.Raleigh,NC 276994636
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24e.For-Water Supply Zic Injection Wens:
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13a.Yield(g.pn14 Method:of tc.st:; •. . . .. „ .,
• Also submit one copy of•thls forth Within 30,days of completion of •
.13h.Disinfection type: - • Amount:ni .„ • ' -weill constriction to the county health department of We.connti.where
• constructed.
Fann.GW-t North Coroltoal -parintent of EMIDIMICIII and Natural Resources-Division of Mier Rmucm. Reused August2013
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