GW1--03768_Well Construction - GW1_20240621

WELL CONSTRUCTION RECORD For I11.rtur'.t .cONl N'
Th6 form can be mod fro singk or milt irk netts
I.Well Contractor IntornIation:
II.WATER ZONES
Stefan Smith rnuM to D■.a Rtrtw►N
Writ C•ontrictnr Nnnk ft. ft.
ft, rt.
3576A
NC Well Contractor Ccniftiark n Nutter15.OUTER CASING(far meNi-caved uclIst OR LINER(U aaicable)
TAOM TO DI;MT TFR TNt'AVTSS NATTRLAI
SAEDACCO ft. t, ia.
Compam Nam: If.INNER CASING OR TURING, la+ed-IwP). �__
VROM TO DLAMFTER T ICK"E55 MATERIAL i
2.Well Conatrection Permit 0: 0 A. 5 n.j 1 IL SCH-40 PVC
Lin all applicable wri pennies tie.County.State,Variance r G)'a'em eze.t --
fi. ft. in-
3.Well Use(check well nsel: ' 17.SCREEN _�
Irlitt.t ' to nt ssto nit Mat Sill THIt1'li[S% I MATiR1cI.
Water Supply Well: ~
5 I[, 10 ft. 1 N. .010 SCH-40 1 PVC PRE-POCK
❑Agncultural OMmticip l.Public ,
OGeothemai(Healing/Cooling Simply) ❑Residential Water Stlppk(single) n' D' as 1
O lndustriaUCommercial ❑Residential Water Supply'(stored) 18'raOOT
IROM TO MATERIAL EMPLACTRI NT MET1100.1 AMOUNT
❑lmgatton ft. ft.
Non-Water Supply Welt: ft i
®Monitonng ❑Recovcry ___ ,
lu jecdon Well: jr, ft.
OAquiferRecharge ❑Gmnndwater Reined iation It RAND/GRAVEL PACKIifappliabk)
❑Aquifer Storage and Rci ovcn O5alinin Barrier FROM to MAn'ar�1. rMrl.at r.MTNr MTrxno
ft. ft.
❑Aquifer Test ❑Sionnnatcr Drainage
n, rt. I I
❑Expennicnral Teehnologx ❑Subsidence Control
i 2n.DRILLING LOG Ialtaci adiitiasal sheets if oecewar'tI
❑Geotltental(C lased Loop t ❑Tracer + rano 1 r0 DF.(RI'PTH)\Roller,ha,Jnr,.,.,uo,.i.[tiw.gain..rc,Acl
❑Geotllemal(Heatink'C'ooling Retumt ❑Other(explain under#21 Remarks) 0 ft l0 ft. sand
ft. ft.
4.Date Well(s)Completed: 5/21/24 Wdl!Da TM -6 rt ft. , .1"...1
5a.WdI Location: - •� L►. �f {,j
ft. rt.Koppers Carolina Pole Site ft. ft. JUN 9 1 ?U./4
.r
RieillI),Chkleer Minx Facilit ION(if applicable) ft. n.
}(441'4+4acEil_PJrf RtRit Li^tj
1901 Wood Treatment Rd., Leland, NC, 28451 n. ft. i DCdi CM;
-i , "Vddiess.Cits.and Zip 21.REMARKS -
Brunswick temp well installed using prepacked screens.
n aatdt Itircelldcaldicahu,N. ill\1
5h.Latitude and t.nn);intik•in degrecsiminutcsisecnnds or decimal degree :: 22.Certification:
(rl ncl:luld art tat I..i,.r.,,dlY�l,ut
N W !' A' 5/28/2024
Signor'! of CctLd
Well Contractor Roc
6.Is tare)the%tilts): :Permanent or 2PTemporary
r y signing able farm,I hereby certify that the seals)wry ferns eenutnrcted in accordance
with 1 SA NCAC 02C,0100 or 15A NCAC o2C A200 Well Constrai nta Swedards and dear a
7.Is this a repair to an existing well: .31 es or LO No cops of Mix,grand has brew prmvded to air well newer.
If this rt IS repair,fill mere krrowe well I a,wtnrrthm anl,,roc riot test explain the norare of the
repair under 121 mantic,'section or at the back of this form 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Nnasber of wells eaas11'Reted: 2 eunslruction details. You may also attach additional pages if necessan.
For waltlple injection or not-wnrer supph wells ONLY with the some coosfiw dew.We can
sabont one fonts. SUBMITTAL INSTUCTIONS
9.Total well depth below land surfaces 10 (ry,) 24a. For Al Welk: Submit this form isithn 10 days of completion of welt
Far aunt*.ells lot Adroit)if dclli•rnu tcrmnpfe-? .'OO'and 2Eo toot constnaction to the foll ning-
IS.Stalk water teetei below top of caning: 5 (ry,) Division of Water Resources,Information Processing I nit.
If water level n , ,. .: - 1617 Mail Service('cater,Raleigh,N('27699-1617
I I.Borehole diameter:3.75" tin.) 2-tb.For Injgctlon Wells ONLY: In addition to sending the form to the address in
24a Aim. also submit a cop} of this form within 30 days of conviction of sell
12.Well construction method: DPT const i tion to the following.
tic.auger.roan.cable.dint push etc I
Oh Wan of Water Resources.Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Rakish,Ni 21tl9l-1636
l3a Yield Omni) Method of[t sC 24e.For N Atertuppls A.Injection N'elh:
Also submit one cops of this loan onion to dat s of completion of
IJb.Disinfection t.)pr. Annome well corlstnuctian to the cotmn ticahh deign ►ent of the county he wtr
cot1M4TUCkd
For111 CiW-1 Noah Carolina 1A IMIimcru Of Em utouuiynu and Natural Resources-Dn mon of Water Raotraa Rea iced August li I t