GW1--05026_Well Construction - GW1_20240828

WELL CONSTRUCTION RECORD g) Forltr<nst Use ONLY:
This form can he'nod for single of sn itipk aces
I.Well Contractor Information:
l 14.WATER ZONES
Stefan Smith i FROM ! to Dr51 tort ittN
Wc11 Colmcka Nair: ft. A,
3576A
ft. ft.
NC Well CoulracforCMifsration Nanbcr i IS,OUTER CASING(for muNttased wells)OR LiNER(Ii eaYk)
• now T, to PRMTTER THItTCNFNs M91711191
SAEDACCO 0 n. ,' 30 ft. 1" is. SCH-40 PVC
Coopam Name 1 Iw INNER CASING OR TU'RINGAgsNbrraial dnrd•1ss))
FROM l IO DIAMETER TBIC'kNFSS MATERIAL -
2.Well Construction Permit 0: ri. ! n. M. —i
Wren apple:ride well permits fie.Canny.Stair,Variare.filEakin err.i .
n. 1 n. in.
3.WeN Vie(duck well seek
SCREEN.scRn-_
Water Berippi,Well: TIIOM TO DIAMETER 7751 yr THIRANT'N% MATTWAI. _
°ARricuMutal ❑MunicipaUAtblic 30 ft. 35 ft. 1" is, + .010 1 SCH-40 PVC PRE-PACK
mal(HearinCooli — f� in. —� -OGeothe K rgl Supply) ❑Residential Water (single)
Olndustrial.Commercial °Residential Water Sttpph•'stewed i ' (a.GROUT
FROM to MATERIAL i EMPLACEMENT 91E11100 A AMOUNT
❑lmpation 0 ft. 26 iL Portland tremie
Non-Water Supply.Well:
n. ft.
RMonitonng ❑Ro otieiy - ..--___„ _,
1Rjecti(Nt Well: n. ft.
°Aquifer Recharge °Groundwater Rcncdiation ' 19.SANDN.RAVELPAC Otagellughlt)
10*1111 TO MATRRIAl, , tlIPL(CEMr.NT'Arnim) 1
OAquifcr Storage and Recovery ❑Salinity Harrier 28 ft. 35 A. Sand 2
OAquifcr Test ❑Stomntater Drat — -
ft, ft.
❑Etcpenmrn4il 7gtihnobec ❑Suhsidcrcc Comm! IC DRILLING LOG lamb a/4111wal sheet,if"woman I
❑Geot er al(ClosedLoop) ❑Trager PROM TO DI.SCRIPt1ON,r..Vr.i.sera.r....wrrltn pt.onto tile.rat.)
°Geolhental iNeatrngCooling Return) Daher(explain under 021 Remarks) . 0 It 15 ft. sand
4.Date Vstll(s1 Completed: 7/26/24 Weil WAM-26 j ' .!
5a.Nil Location: f ft. AUU 2 S 2024
Towngate Cleaners n. n.
F.,,:,In, <1,„rr N;,n. Fatllm IOkfiCapplicabk) ft. n. 1Gt.,:rs; ; 9.'."ZeNlii 4+
a--..6
t.
715 N Howe St., Southport, NC, 28641 f ""fr
Phssical \dlrrti. I ,,, ,,.':'Vf. ' 21.REMARKS
Brunswick Bentonite seal from 26-28'
cousin P,rcel ldennli ationNo IPiNI
•
56.Latitude and Longitude in degirts/minutetoSeennds or decimal degrees: 22.ferdticatiDn:
(if sett ftcld ,sow tat long n.tdlkknn
53.923577 K 78.023376 W !' A' Cc 8/8/2024
Sigler"'of Well Contactor Date
6.G(ate)the wells): KiPertsanrnt or 'Temporary in signing(hie form.1 hereby eerrifa that the wel.'si secs Icreef constructed Of an rardrmnr
wits 1 S4 NCr4C(12C,0100 or 154 NCAC n?C.t200 Writ Commit rural Standard.end rhos o
7.la Ibis a repair to an existing ecR: 291'cs or ❑No crept of rho record has fees pnwided rrr Mr well owner.
If Ws u a et,cu. fill,.sot(mono ,,,.,,. nw I1'rsn itfrtnataw no and r triton Mr rrrrtfe of rite
repair rider*2l remarks see Vi.m or sot rho hark of Mis form. 23.Site diagram or additional well details:
You mat use the back of this page to pros ide additional well site details or well
8.Number of web oassouseted: 1 construction details. You ma'also attach additional pages if necessary.
For mahlpk injection of anw-water ngrpfr wells ONLY with the sags*coeoI aeafeu.wit nun
Aging'.one form. SUBMITTAL INSTUCTIIONS
9.Total well depth below laud surface 35 (ry,1 24a. For Al Wells: Submit this font, w ohm tU da}s of completion of nell
For.„air pro well,lost off drprh,ifdifirrou+r..o,pfr-('''I M1-am/'41 io i i construction to the following-
Ifs.Static water level below top of caul. (h.I Division of Water Resources,Information Pi cers41*U.N.
ifwMIM Ilevel a oboe,(1Slag.u•< 1617 Mail Service('enter,Rakigh,NC 27699-1617
I I.Borehole diameter:3.75" (IL) 24b.Far loiectitru Welts ONLY: hi addition)to sending the form to the address in
24aabuse. also submit a corn of this form within z()days of completion of well
12.Well roustrwYinn method:DPT construction to the fi)llowing.
II e.anger.roan. :ihlc.dleeci push.etc l
Mishit'of Water Resources,Undergnoind injection Control Pru ram,
FOR WATER SUPPLY WFi.I.S ONLY: ION.Mail Sen ice(enter.Raleigh.NC 276194636
13a ti edd I�wtil �h rlw,d„f rc.i: 24e.Fur Water Supptt &Injection Wells:
Also submit one cops of this form onion sit da_ts of completion of
Ith.Disinfection type: Am,nuu: well construction to the county heahh deportment of the counh•wire
.onstructcd
Form GW-t North Calcium I)tpunnriu of Ent mums u aid Natural Resources-Desks of Water R6otrr>o Ite%tied&tguat II,I