GW1--04989_Well Construction - GW1_20240828

WELL CONSTRUCTION RECORD For treenail l.'seONI_V•
This form can be used for single or multiple„ells
1.Well Contractor Information:
1 14.WATRR ZONGS
John Eisenman MOM TO DESCRIPTION
Well Contractor Nana R. ft,
R. in,
4439
NC Well Contractor Cenils.lion Number J 15.OUTER CASING(for mu k ird%ells)OR LINER III ap likable)
FROM TO DIAMFTFIT THICKNFcs Al AU'RMI
SAEDACCO H. n. iu.
Comp/tat Nana K.INNttt CASING OR TIMING tjerthernial closed-kkup)
FROM TO _T DUNFTFIt 111CKNrSS NATTRI(1
2.Well Construction Permit I: 0 ft. 10 ft. i 2 SCH-40 PVC
Lia all appli.alde oeh permit.ire.County.Stale.Variance ftfectiat rlr.1 — - ,
It R. la.
3.Well I're;check well use): It SCMIZR
Water Supply Well: PROM TO DIAMETER SIOTMIrr THI(T(NR3l MA1UIM.
LIAgricultural DMunicipakPublic 10 R. 20 R. 2 O10 SCH-40 PVC
11Geothematl IHeatinglCooling Supply) DResidential Water Supph 'single)
R. ft. is
1IIndustrial/Commercial OResidential Water Sitpph iskired) 1t'
PROM TO MATERIAL EMPLACEMENT METHOD A AMOUNT
❑lmgalwn 0 ft. 5 ft. Portland pour
Nom-Water Supply Well:
XMnnnonnc 1114.o_, ,_r-.
Injection Well: n.~' n.
0 Aquifer Recharge ❑Groundwalcr Renicdiation I".SANOK:RAVRLPACK I shie)
_YNIISI It) MATtRlil. Y.NW.WIM1'\T MITIN)n
DAquiler Storage and Recovery ❑Salinity Barrier 8 ft. 20 ft. sand 2
❑Aquifer Test ❑Stormssatcr Drainage
II, R.
❑E'penmental To:titmic% ❑Subsidence Comm!
29.DRILLING LOG(attach additional sheets if ncertsars 1
❑Geothermal{Closed Loup' ❑Tracer FROM To DESCRIrtitN i...Mr,w.rdm'...MAI.'i.I,pr.grin mot%.«
DGeottemral(Heating+Cooling Return DOther texplain under 1121 Retuarisi. ft. n.
ft. ft.
4.Date WrU(o)Completed: 7-22-24 well IDItMW-2
Sa.Well Location: ft. R. .• .
"^ is....,:. • 4._.D5.f
Coastal Dry Cleaners R. ft. AUG 3 8 2024
Facilit .'Owner Name Rican,HM(if applicable)
R. N
545 Castle St., Wilmington, NC, 28401 R. n. if r;..r;n..
'
T.; j rJi'
s Ci Plnsical Addicsn.and [M
ZIP il.RARILS i•;,..:' _ :
New Hanover i bentonite from 5-8'
(nano Prrccl lde ta,hrrliur,No I PIN {
I
51i.Latitude and Longitude in deypecsiminutcsisccnnils nr decimal degrees: 2L Certification:
(1f well led.,nr I:wlotig in sidlleainl
N W - 8/12/2024
� -
Signature o f^ ±e."ti. _ Ddc
6.Is larch the welled: X Permanent or Temporary
r ,�,. �-,ss���'so✓T
Ill sign'''. Ail Jong sfr 5.5.7-: ..C344.:is i D:e:cI trots:m ted in aaronianie
with I M NCAC OH'.'x •-t i il7As....' .0200 Well Comoros-rim Srandaeds arld teat a
7.IN this a repair to an existing well: _71'es or IG No r.Ts of thi.re:nrd ha,firer provided to the ter?!owner.
If Obis as a,opal'in.net anima aril.rr.u/,1r hem Injr,rrnanw,a,ul rcplonr die nonce of the
repair weeder 121 remark,section or ton the beck of this form. 23.Site diagram or additional n ell details:
You too y use the back of this page to pros ide additional well site details or well
8.Number of wells constructed: 1 c-ornttueliun details. You may also attach additional pages if necessan.
For roahspir asjerrhm Of ena•wntr,.sppls wells ONLY with Ihr SOW coaatractiou u.0.,a,
submit one h.ma. SUBMITTAL INSSTQCTIONS
9.Total well depth below lad surface 20 (fl.) 24a. For All W'dli(: Submit this Puri within 30 days of completion of well
For mahipir wells list all depths ifaiiferrn,rr.)m%pfr•.10700 cud 2Er ffMY1 construction to the following;
10.Stark water level below tat of cashap (Di Division of Water Resources,Information Processing I nit.
If wake level it,serve Ivies.ow'+.. 1617 Mail Service(cater,Rakiagh,NC 2 7699-16 1 7
I I.Borehole diameter.8.25" (in.) 21b.For Inketioo Welk ONLY: In addition to sending the form to the address in
24aabose. also submit a copy of this form within 30 days of completion of well
12.Well cosistnietinn method:HSA construction to the following_
t i.e.auger.roan.cable.direct push.etc.)
Dhisi)n of Water Resources.Underground lujectiou Control Program.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center.Raleigh.NC 27699.1636
1Ja l idd IEPmI Method of test' -_ 24c.For Water Supply .5,Injection Welts:
Also submit one cops of this font within to days of completion of
IJh.Disinfection ty pe. Amount: well canstntctton to the county health depanment of the county where
- -_ .. - constructed
f.o m.s r a-I ♦i i a cantina Dcpmtrmu of Ern imtms-iu and Natural Resources• Dn is ion of 13-net Resoircm Revised Mates 24)13