GW1--03764_Well Construction - GW1_20240621

.WELL CONSTRUCTION RECORD For rnernrl Use ONLY'
This form can be used for sink or multiple wells
I.Well Contractor Information:
ii.WATER ZONES
Stefan Smith ►MOM TO D041OP•TN)rr
Well Contra-lot Nark ft. ft.
ft, D.
3576A
NC Well Comntctor C coif,.:elan NumberIS.OUTER CASING(fur atuMi-caved wells)OR LINER tit able
IRON TO tO %tE7r5 Ttlm'KYrss HsTYNtst
SAEDACCO O. + ft. .. is.
Compun Name le.INNER CASING R RINGhegbermai dined-Loup)
rMON _to DIAMETER 1111(10.F S N.liT RI'di
2.Well Constreedoo Permit I: 0 ft, 3 N. 1 i- SCH-40 PVC
Ilse ai applirnbk trra permits flee.Crwllty..Sitth'.t ariam v f1ICbOt eh'.t f1. i_ n. . .
3.Well I '.e lchcd.sstllseek 17.5('RLLN 1
N Ater Sunnis Nell: ;mom TO DMITFR j SLOT Sill THllWOON. %ISTFN1,41,
UAglwuhural lJMlticipal,Ptlblrc 3 ft. ` U
13 ft. 1 ra. .010 SCH-40 PVC PRE-PACK
OGeothermal(Healing/Cooling Supply) OResidennal Water Supply tsingle) ft. ft. is.
OhdustraUCommercial ORcsidcnnal Water Suppl (shoed) tLGROU'T
/ROM ' r0 MATERIAL EMPLO:FMriT METHOD i AMOUNT
❑Irrigation n. ft.
Non-Water Supply Well: s
W Monnonne ORccos cn .
Injection Well: � n n
°Aquifer Recharge FICimiindn:Ttcr Rcmcdiation Imo ttk.SAND/GRAVEL j
►'NrIN TO Stsri'Ill'.i INPL FA
IT MI Tn(rn
OAquifcr Stontgc and Recover) ❑Salirwty Ramer ft. n.
❑AgaifcrTest ❑Slormn;terDrunage ft. ft.
❑Experimental Technology ❑tiuhstdcncc Comm!
2a.DRILLING LOG laaach additional sh(s:ts it ttccessars I
❑Geothemwl(C'Iuseti Loop► ❑Tracct PROM TO 11.e_Rnnos r...6r.trrod.w..,wirrnkl.I,pc.er.a.re,tree►
❑ erm Geotlal(Neatine)Cooling Relum) Dotter(csplate under /2I Remarks i 0 ft. 13 ft. sand
ft, fL • .
4.Date Well(r)Completed: 5/21/24 Well IROTMW-5 r .. • • l .
Su.Well Location: i
n' ft. JUN ? 1 2024
Koppers Carolina Pole Site ft. n..
Facrlits a9ss rer Nam( Facility ION(if applicable)
rt. ? n. trr0ormaii-en rre.,-rm sm U
1901 Wood Treatment Rd., Leland, NC, 28451 n. ft.
h„.:.t,address_City.and Zip It.RCM ARKS
Brunswick temp well installed using prepacked screens.
--Corms, hercc)identification No (EMI
Sh.latitude and l.angirude in rk trecs,ntinutesiatennds nr decimal degrees: 22.Certlficatit►o:
;rl wcl:(kid lilt I:ulnug Is arlllcunl{
N W 5/28/2024
Signor' of Cc (red Well Contractor Dale
6.LY tart)the well(s) ❑Pernrtlaesl or %''lcmprrcars Hr signing this form.I hereby certify Mar the wralst brats fwrre)trrnrtructed in acrordanrr
oh I SA NCAC 02C.0100 or 1•(A NCAC( C.0200 Well Coratrarnon Standards vend that a
7.Ir1 this a repair to an existing well: __;N es or $':tilt VI of Air word hay been provided to the hell owner.
If this is a repair,fill lnlr knoww nett r.<ntstlur boo ortornartam and,'.°tool the n,rrare of the
repair tattier 121 remarks ve il..,or on the bark of this form. 23,Site diagram or additional well details:
,r ,nas use the back of this page to prosaic additional well site details or well
8.Number of wells constructed: 1 ti'uslluctioo details. You may also attach additional pages if necessary.
Ior main*Infection or nom-note,srTph wells ONLY with the unto cusralracafosl.our can
sabmit one fmna. `IIBMITTAI,INS.IUCTIONS
9.Total well depth below lard surface 13 (ry.i 24a. For AU Wells: Subusi dos form union ?t1 days of completion of well
For multiple wells list all depths ifdOreat te.rmwpfe-f 2p7'oral 0+r'y Constnlction to the folkwing-
1U.Static water kid below tup of casing: 5 (II.) Division of Water Rcscturees,Information Processing I.nit.
if sill.,h'sr)IN rrbnrr I os,aq o4•". 1617 Mail Seri ice(eater,Raleigh,NE'27699-1617
II.Borehole diameter.3.75" in.On.1 24b.For Ink'ctioa Wells ONLY: In addition to sending the form to the address in
24aabose. also submit a copy of this font within 30 days of completion of well
12.Well construction method: DPT construction to the folios ing.
li.e.aimrr.reran,cable.direct push.etc 1
Dhlsion of Water Resources.Underground Injection Control Program.
FOR WATER SUPPLY WELLS ONLY': 1636 Mail Sets ice('enter.Raleigh,NC 2-699-1636
13a.Yield(Rpm)_ Method ofp� 24c For Water Supply&Injection Welts:
Also submit one '.ropy of tins loom rrithrn ;a da_ss of completion of
13b.Disinfection n me: Anwnt• well construction to the county health department of the counts where
• constructed
Form GW-I N'onh Carolina Dgxulnt7n of Em mums!and Natural Resources-Do sloth of Water Resumes Re%tied Argos[20I?