GW1--03765_Well Construction - GW1_20240621

,WELL CONSTRUCTION RECORD For Internal Use ONLY:
The form can be used for singk or multiple oc Is
1.Well Contractor Information:
Ls.'Am EOM
Stefan Smith PROM TO DESCRIPTION
ft. ft.
Well Contractor Nam:
ft. ft.
3576A
NC Well Cotnmcror Certification Number
15.OUTER CASING AY►(Ini IAMICtltri OR LINER fif a�ca T
PROM TO 1 Dr1dILI[R TUNE Of 111 MATERIAL
SAEDACCO n. n. Ia.
t,tt q,a m Name I6,INNER CASING OR SIG(i sthrrt al elned•hap)__. ..__. _,
PROM TO DIAMETER TSKT:NESS MAMMAL
2.Well Construction Permit if: 0 R. 3 ft. 1 is SCH-40 PVC
Luz all applicable writ penelds(is.County.Starr.Variance.ilttliat err., - + - -'
M.
3.WeR Use(cheek well wade 17.SCREEN
Wiser Supply Well: FROM TO D1AstfTI:a vl.1)1',I.T MI(KNES5 I MATERIAL.
❑Agricultural 1_1MunicipaVPublie 3 ft. 13 ft. 1 010 SCB-40 PVC PRE-PACK
❑Geothermal(Healing/Cooling Supply) i lResidential Water Supply(single) ft. ft. M.
GRO
I IIndustrial/Commercial I'Residential Water Supply(shrtrd) 1e OT
FROM TO MATERIAL IIMPLACTMLNT METHOD a AMOUNT
❑lmgatuon h. ft.
Non-Water Supply Well: R. R
SIMonitonnu; ❑Recover
Injection Well: n. ft.
CI Aquifer Recharge ❑Cmoundw'ater Rancdi:uion 19.SAND/GRAVEL PACK Of applirablel
FROM i TO j sis mitt si. /Am.arEMI TMVTNOD I
L'Aquila Storage and Rccm'cn ❑5alintty llama ft. 1 ft, 1
°Aquifer Test ❑Stomncatcr Drain:ge - --
(I, A.
❑Expetitnrntal Technology ❑tiuhusiderce Control 211.DRILUNG LAG A ntacb additional alleitlllsecenanl
❑Geodrnnal(Closed Loop) ❑Tracer PRIIN TO nest RlrrtoN rosier.bovine.,..aan.•I.tour•0-10•:e..u.)
❑Geothermal(HeatingfCooling Return) ❑Outer(explarl under#21 Remelts) 0 tt. 13 h, sand
ft. R.
4.Date Well(s)Completed: 5/21/24 Well 1DN TWA-4 s j'
ft. rt. r.L.�.,.... L.FL/
5a.Well Location: ft, ft
Koppers Carolina Pole Site II. ft. JUN 9 i 2024
Pa ilitylONnerNwne Facility IDM(if applicable) II. I ft. �lr T*'i ul t~,rr:.Mts:'!4ig Ufa
1901 Wood Treatment Rd. , Leland, NC, 28451 — II. rt. VPKd.C.)4
Pln sisal Address.City_and Zipi ,
1.KILN,�RhS
Brunswick temp well installed using prepacked screens.
t..i a r, Parcel Ideaaitktaioa No.(PINt
5h.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
o oil:frdd uaa lot-Iuug it mt ilk:ttaa) •
N Wr 5/2e/2024
Signor ofC .,rod Well Contractor Date
6.1s fare)the well(s): OPermaneW or BiTempurary
By signing this form.1 hereby/rrtlfy that the«Why!Nos(*we)evmrtra.ted to acrordtmtce
with 154 NC4C OK,O209 or 154 NCAC 02C,02(0 Well Construction Standards and that a
7.Lz thin a repair to an existing well: 11 es or K do ropy of this record has been pmytded to tar well owner.
l/this It a repair,fill 0/0(twin wall cotton&ne,rnp'n,u:u,"t un,l.•tj+ial+l the Iafare of the
repair fowler 112I remarks.rectum or re the hark of this form. 23.Site diagram or additional well details:
You may use the back of this page to pros ode additional well site details or well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For malt-tote a tjo 11001 as non-wart sapper wells ONLY with the same construction ..,:u:uo
submit..rte tone. SIIBMITTAI.INSTIICTIONS
9.Total Hell depth below land surface: 13 (ft.) 24a. For AR Welkin Submit this form within :4l tins of completion of well
For maltrple wells tot WI depths 0 dal)erent rtaontphe- ? 2tMT and 2Ee Awn construction to the following-
/II.Stat)e water lesel lulu% sup of caving: 5 (11.1 Diy'iziun of Water Resources,Information Processing Unit.
1617 Mail Service('enter,Itakig6, 7,.,.. . . . ,.. VC27699-161�
1 I.Ili rehote diameter:3.75" (in.) 24h.For Injection Welly ONLY: In addition to sending the foam to the address in
24a sbus e. also subunit a copy of this form within k) days of completion of well
12.Well construction method: DPT coustntcbun to the lolloss ing
ti.e.auger.rotary,cable.direct push etc t
Ohision of Water Resources.Undergr 1 Injection('untrol Program,
FOR WATER SUPPLY WF I.LS ONLY: 1636 Mail Service Center.Raleigh,N( 2769)-1636
13a Yield IRhtn i _ Mrrttnd of n ode 24c.Fur Warr Glpplc A',Injection Wells:
Also submit one cops of this form nithnl '0 days ofconopietioiof
136.Disinfection type: Amount: well construction to the county health department of the county where
constructed
Fonts GW-I Plonk Catalina Department of£ac Imlmuetu and Natural Resoerces-Dn lion of Water Rennes Re,used August 2013