GW1--05033_Well Construction - GW1_20240828

WELL CONSTRUCTION RECORD For lmcn IUseONLY:
The form can be toed for single or multiple steles
I.Well Contractor Information:
14,wan BOYS
Stefan Smith PROM I To eterlef Tn)\i
Well Contractor Name R. ft.
to. (I.
3576A
NC Well Contractor Certification MutterI S,OUTER CASING Ito►miiiii-eased new OR LINER III likable)
FROM : TO MiNTTFR 110K11VATS. N\TTRIAI.
SAEDACCO 0 ft. . 29 rt. 1" is. SCH-40 PVC
Compass Nate to.INNER CASING OR TARING t.r.Yermalld ii d4.op)
PROM TO DIAMETER THK'A\F55 N\Ti'RI\I
2.Well Construction Permit ill ft. ft. to.
Liu all applicable urn pererili li r.County.State,Variance.Inferborl ea.) --
R. It
3.Well I-se i check Sell owl: ( 17.S(REEN
Winer Supply Well: f retool TO MANNTER AlOT 17JJ THt(liirNs MATNMI. _
OAgricultural pMunicipal/Publk 29 R. 34 R 1" 010 SCH-40 PVC PRE-PACK
OGcothennal(HeatingCooling Siip lr•1 [Mesodermal Wafer Supply'(sitlale) IL It. in. -
Olndustnal+Commercial OResidemiad Water Supply bilmn d) llrdT To MATERIAL EMPLACEMENT METHOD t AMOUNT
❑&npation 0 ft. 25 R'. Portland tremie
Non-Water Supply Well: H R. R.
Elkton'tonne ❑Recovery
Injection Well: R- n.
❑.Aquifer Recharge ❑Ciroundw:ater Rentcdia Lion 19.SA�•��♦-YELPAQC�tmuRpolr)
❑Aquifer Stontgc and Recovery ❑Saline\Hamer 27 I TO MATRRIAI. r.NP1.ACFNK\t NFttMn
( R. 34 R. Sand 2
❑Aquifer Test ❑5tommatcr Drainage r__ fI, R.
pE'enmcntal Technologs ❑tiahsidcncc('otiml
20.ORII.USG 1.O(r 1a11acb addilional speeds if airman)
❑Geeothemwl(Closed Loup i ❑Tracer roost to Dry sirnOs,tmi..%h dra..,r"nvnrsnrr.WON.r.de.)
❑Geothermal(HeattntC'ooliug Rem nu ❑Other te\plam under 421 Rentedts) 0 R. 15 n. sand
ft. II.
4.Date W'ell(s,Completed: 7/26/24 Well IDOMW-27
Sa.W >< `
n. ourWell Location: R. II.
Towngate Cleaners It. n. 1024
Facility'trercr\la,... Faedtq MU Of applicable) • n.Y rt. )fxv`r:ri F:f ;•'r,cy►q.r,
715 N Howe St. , Southport, NC, 28641 ft • rl • D'tAiCyllGa
Pinsical Ad ivhs.Cm.andZtp �21.Rt_s1ARkS J
Brunswick Bentonite seal from 25-27'
('outlay Parcel Idcsoda.du,t,No IPINt
Sb.Latitude and Longitude in ikgmes/minutes/seconds nr decimal degrees: 22.Certification:
Of wet)field,mw Iaillenb'at.,dli:I nl1
4051
53.923577 N 78.02337E W 8/8/2024
_
SignaldY�of Cc.. ted Well Contractor Date
6.Is(ate)the well(sk It Peron istt t ur OTemporan
M tiVliTg!kit font,I kearbe certify alai the well tAl tem tttrrrl con necied 117 accordance
tart 154 NCAC OK.0I110 or I SA AICAC 02C 0200 Well CanaNrn lion Straad,rdt and rlaa II
7.Is obis a repair to as skating well: I9Yes or ❑NIL ropy of chit record hat fora provided to the urn owner
if ilia at a repair fall,oar<mrwr well•amigo.WO rujurnarraal IOW a epktin rho iN.lree of Mr
repair!marl f21 remark.,.lr,n...or t.Ni the fad'.(of chit form 23.Site diagram or additional well details:
You Ills) use the had,of this page to pros ode additional well site details Or well
Ii.Number of wells constructed: 1 construction details. You mos also attach additional pages if necessary.
for malnplr n+icr molt.a 91NI-N]aer•up/4.N't'IIS OAf ,all,Our tame raastsfrtwOon tom rum
ulektlir one from. SUBMITTAL INSTUCTLONS
9.Total well depth below laud surface: 34 (no 2.1a. For All Wells: Submit this font) %%ohm iu days of completion of well
For madrrpk wells lit all depth,ifdrpeL•.I:rraar,plr-?Ps)Isi'.,o°rR 10111 Con tnlctlnn to the following-
II.Stalk water level below tap of canny (ft.I Division of Water Resources,Information Processing knit.
flower keel it above madam.ate"+' 1617 Mail Service['enter.Rakish,NV 27699-1617
11.Borehole diameter:3.75" tin.) 24b.For laicedon Weis ONLY: In addoan to sending the form to the address in
2aaabose. also submit a copy of this form within ut dins of completion of well
12.Well construction method:DPT construction to the following.
41 C.anger.treat.cable.direct push.et.
Ohisitn of Water Resources,I.ndcrNntund Injection Control Program.
FOR WATER SUPPLY WELLS ONI 1: 163E Mail Sets ice(enter.kakigh,N( 2769'9-1636
13a.Yield Igpm► \ta-thn i.it test:
24c.For Water Supple 8 Injection Wells:
Also submit one copy of this form within :0 day'sof completion of
lilt.Disinfection type: 1m„un1- well construction to the county health department of the counts where
constructed
Fenn GW-1 None Carohal Oeponntem of Ern Ilomll:au tel Natural Resources-Bra Sloe of Woe(Resouca Res toed August 2011