GW1--03767_Well Construction - GW1_20240621

WELL CONSTRUCTION RECORD For Internal Use ONLY
This form can be ns.:d for singe or multiple edis
i.Well Contractor Information:
Ilk WAIIR ZONES
Stefan Smith VROM TO 1 DWM'RIPin►N
Well Contractor Name R. ft.
ft.
3576A «
NC Well Contractor Certification Mamba1 S•_OUTER CASING*for mutt vcNFt OR LINER tit an itcabk)
FROM To OtttITIFTR TRICK NESS MATERIAL
SAEDACCO h. « is.
(•amp;uy Name.: I6.INNER CANING OR'IT.BING1l,authcrfaleimed-1 1
Ir tl ' TO PI tt4F ITS THICKNESS MATERIAL
2.Weil Construction Permit N: 0 ft. 3 ft. 1 in SCH-40 PVC
list 011 applicable evil permits(Lv.Cowu.Starer.Variance.6Y&bu7(ell.1 1
ft. ft.. in.
3.W'dI Cse(check well trek n.ti(RE-IN
Water Supple kelt 'Rost lit eel'tfl..14 F ,I Ili,1/ 11111 WM,. m s 4 t to at.
3 ft. 13 Ii. I 1 .n .010 SCH-40 PVC PRE-PACK
O Agr►cultural LIMunicipal/Public
OGeothennal lBeating(oolinu Simon t 11Rcsidcntial Water Supply(single) ft. «
Dlndustrial/Conunercial I (Residential Water Supph (shared) 1tl CRO11T
FROM TO .I tlf Hill 4tIPI HF.Mf\1t11.TIIOOl AMOUNT
❑Imgation ft. ft.
Non-Water Supply Well:
«. R
ElMonitoring ORecover
Injection Well: «. ft.
°Aqutkr Recharge °Groundw'ater Remedial ion tl.SAND/GRAVEL PACK lit Awl ii•abiel
1R11,M To sr trt lu st. ,MPI.%(EMENT MIETROD
❑Aquifer Storage and Recover ❑Salinity Harrier ft ft. —
❑AquifcrTest oStormssatcrDrainage , -
«. ft.
OExpenmcntal Technology ❑Subsidence(Control
2a.DRILUNG LOG(Mani additional dteHq if arcrmarj
°Geothermal(Closed Loop) ❑Tracer most 1 To ors wipr,ON i.wl.r,liarshwas,...a'nxt.t.Pr.rrr.n ere,tit I
DGeothedmal IHeattng(C'ooling Return) °Other(explain under 421 Remarks) 0 ft. 13 ft. sand
«. n.
4.Date Well(s)Completed: 5/21/24 Well iDNTMW-2 «. ft. _Lr th.»'.: !.'• ,
v /
Si.Well Ltteatwrn: «. rt.
�. --- 1
Koppers Carolina Pole Site ft. n.
Facilin'Os ncr Nark Facility iDN(if applicant.:. R. to, it r YrT -f
1901 Wood Treatment Rd. , Leland, NC, 28451 ft. ft...
,Itssteal Address.City.and 7tp
- 21.REMARKS
Brunswick temp well installed using prepacked screens.
Gait I. Parcel Ile l lleatiom No.(PINT
ib.Latitude and l onginad a in dettmes/minntesistcnnds nr decimal degrees: 22.Cer1ificatirn:
(duel'field,one to long ix xtdlkic4a{
N W _gml ofCe.��Yd Well
C 5/28/2024
Sigrmt ofCc.:tied W'cll Contractor Date
6.la(are)the wellls): ❑Permanent or EITemperary
Its signing this form,1 hereby ter*.that the welko war twervJ canstrae'led in occondaarr
waft 1 SA NCAC 02C.0/00 or 15A NCAC 0 C.0200 Well Construction Sroadrrrda our rlatr e
7.Is this a repair to an existing well: °Yes or iG No rnpr•of Mir word has been pan ided to the well rneiter,
/f this u a repair,fill r,wr ta,.oa 1...i1...eurtw AWN arfornxautm and explain the nature of Nie
repair ander 021 renarrts section or OR me bark of Mir farm 23.Site diagram or additional well details:
You man use the buck of this page:to pros ide additional well site details or well
8.Number of wells olnretrueted: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water sippls wells ONLY with rho wine construeflow.Non can
submit one forma. Si IBMITTA1,INSTUCTiONS
9.Total well depth below lard terrace 13 (ft.) 24a. For AR Wdls: Submit this fano withm 10 days of completion of nell
For maniple wells list all depths ifdtfirear in-ample-.?0 IOW and 2R/(r(r') constnrction to die following-
1i.Slade water level below sop of casing: 5 (ft.I Division of Water Resources,Information Processing I.nit.
lf..aie,let,el P.0.0.r•n sit 4. N.,• .' 1617 Mail Service ice(enter,Raleigh,NC 2 7699-1617
11.Borehole diameter:3.75" (IL) 24111.for injection Wells ONLY: hi addition to sending the form to the address in
24,E abm e. also <_1 .1010 a copy of this form within 1) days of completion of well
12.Well construction method: DPT col stmaton to the toIloutog.
(i.e.anger.ratan'.cable.direct push crc
Dhision of Water Resources,Underground Injection Control Program,
P
I.-_(r1t11 ‘IFit,I l'1'11 WELLS ONLY: 1636 Mail Service Center.Raleigh.NC 21699.1636
t3:► Yield(gym) Method of test: 2k.Fur Water Sappls t.Injecting Wells:
Also submit one copy of this form within 10 days of completion of
13b.Disinfection type: Amount: well constriction to the counts health department of the county where
constructed
Form GW-I Nonh Carolina Department of Fat ttottrtrtm ant Natural Resources-Dn sloe of Water Rrotrea Reused AtgIISt 101.