GW1--03769_Well Construction - GW1_20240621

,WELL CONSTRUCTION RECORD For ltiernnI Use ONLY:
This form can be used for single or amshipk wells
1.Well Contractor Information:
14.WAVER ZONES
Stefan Smith room to OP-SG•RIPTION
Wd1 C'omm:lot Nang ft. ft.
3576A ft. ft.
NC Well Contractor l enitk.ili n Numttct 15.OUTER CASING(far swMi-caved w dhi OR LINER(Y )
►ROM to DI1,Murra 11110 MESS MA1TRIA1.
SAEDACCO rt. rt. ia.
Cowan)Nan: 1i.INNER CASING OR TUBING tj a r _d daaidaaapj
PROM TO DI\METER -T THICKNESS MATTRIAL
2.Weil Construction Permit A: 0 R. 3 ft. T 1 ++. SCB-40 PVC
Liu all applicable well prtmits fie.County.S .tariarne.1r'ect,'ort tar.!
ft. ft is
3.well Coe(check well■see: 17.8CR1231 -
Water Supply Well: PROM TO UtAMLTRR MOTn17, TNI(1sNRNa M.4TERIAI.
L1AgIwulturJl ❑MtuwcipaUPtrblk 3 ft. 13 h. 1 ha .010 SCH-40 PVC PRE-PACK
OGeothennal1Heating,Cooline Supply) OResidential Water Supply(single) R' rt. i.
Olndustrial.Commercial OResidcnual Water Supply(shtred) 118. m 70 MATERIAL [MitLACEMENT ML71100&.4MOl:\T
❑Imp;ttron ft. R,
Non•W'alcr Supply Well:
anMonitonng ❑Recovcn'
injection Well: R. R
0 Aquifer Recharge ❑Groundw'atcr Rcnedi:uion If. Vl1LPACIC tlTiIftI 11} j
CAquiler Sit-MIgc aid Recoven ❑Salinirt Harrier /IIQM TO MATRRIAI. lHI L‘IF\IY\T Mr'TfNf It
h. ft.
DAquifer Test ❑Stommatcr Drainage
ft. IL
❑Expenmcntal Technology ❑Subsidence Comm'
N.DRILLING LOG tallish additional Ikeda if aecessan t '
❑G othcnmd(Closed Loop) ❑Tracer roost to OSSCRIrtntN rt am%bstraw.(,rra'n:k bee.Va...t•.c*.I
❑Geothermal(Neau Rehm it Rett ❑(]titer(explain under N21 Remarks( 0 h 13 ft. sand
ft. R. a���i • .:
4.Date Welts)Completed: 5/21/24 Well IDeTMW-1
ft. ft. L"'
5a.Well Location: R. If. JUN 1 2014 1
Koppers Carolina Pole Site rt. R. (f1ioil1t4A1iM1 PTGrAiDegitir I too
Facility,,Du tier Nano Facile,ION Of applicable)
rt. ft. DtliflatSOG
1901 Wood Treatment Rd., Leland, NC, 28451 R. rt.
PMsical Address.CM.and Zip 21.REMARKS •
•Brunswick temp well installed using prepacked screens.
Cou*I Narelhk,narrcatisnNo IPINt
5h.Latitude and l.ongitu/k in degreesimiamterincennds or decimal degrees: 22.Certification:
(11 well held.on.:I:o long r.sWlicknnl
N W , ^""" 5/28/2024
Sisaun,:..),f t-'c. Well Contractor Daft
6.Ls(ate)the well(*: ❑Pennaaeet or R'Temporat}'
$r signing Ills Jbtm,f hereby certify that the wrlf(sl ran frrrrrJ cvtwtnrcmd in accordance.
with I5A NCAC 02C.0100 or 15.4 NCAC 0:C,0200 Well Couutrve oar Spaniards and the:a
7.La this a repair to as existing w ell: D 1 es or K No rope of the woof has bars prm•ided to Or styli owner.
if this at o repair,fill Isar tattoos net.tHbl/((Belli injrrrnaU o,(Ind 4.VPiatn the Moire of Ill.'
repair under 021 reaaris srrtsae or as the bait of this form. 23.She diagram or additional well details:
You may use site back of this pap:to provide additional well site details or well
8.Number of welb coastrwyed: 1 cotistniction details. You may also attach additional pages if necessary.
For nwhlpfr mfn•lltst Of ties-water supph wells ONLY with the mass constriretion.v,w(vie
submit one farm. SUBMI7TA1.INS I'LJCTIONS
9.Total wdl depth below load surface 13 (p,) 24a. Fur All Wells: Submit this form within 10 days of completion of well
For meldpie wells lift all depths ifdlfferent tr.rawaple-(@200 and 243'10111 constnlctton to the fattening-
III.Static water let el Inflow top of casing: 5 (ft.) Division of Water Resources,Information Processing I nit.
1/••;'s: ,. , . 1617 Mail Service('cater.Raleigh,N('27699-1617
I I.Borehole diameter:3•75" (in.) 24h.for Irtjsction Welk ONLY: fa addition to sending the form to the address in
'.la,itw\e. also submit a cops of this form within 30 days of completion of well
12•Well otosf r ictinn method:DPT :unsiniction to the follow mug
,� .u.:.r.r,,..i,,...IN. affect push.ec.;
Dhfnion of Water Resources.l ndergnsand Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh.NC 27699-1636
13a Veld(Asps( 1Nelbsd A 2 k•For Water Sown&injection Wclh:
•\lso submit one copy of this loon uithm is da\sof completion of
lib.Disinfection tripe: Atarstrat: s\cll conslniction to the county health denutment of the count} where
constructed
Form GW I Nona Caroluia Liqattnnwtiu of Em minima and Natural Resources-Disxba of Wald Rauwrces R..Isrd August NI