GW1--05028_Well Construction - GW1_20240828

WELL CONSTRUCTION RECORD For Intents!Use ONLY:
This form can tic aced f w single of multiple wells I
I.Well Contractor Information:
la.WATER ZONES
Stefan Smith non TO IMORMIPTION
Well Contractor Name R, R.
3576A n. R'
NC Well Contractor Certification Minter IS.OUTER CASING(for nwMi eri d welsh Oft LINER IU
PROM TO DI'MTTFR THK'K\Tcs NHTTRI tI 7
SAEDACCO 0 ft. t 24 ft. 1" +w. SCH-40 PVC
Compcutl Naar ni.INNER CASING OR T JIBING(Merton dwN p)
FROM TO DIAMETER MIK1i�1SS MATERIAL '
2.Well Construction Permit N: ft. n. is.
List oil.epphi anal,well promo,is r.County.Serer,t'.oiawce.byectiort eta.i
R. ft. u.
3.Well I-'oi check%% llu.ri: 17.5(RIZN
W'aterSupph Well: FROM TO ol4MITER MOT SW THICK'ir:\S i MATERIAI.
CJAfttwnhural OMstlkipal.Pubhc 24 ft. 29 R. 1" ill. .010 SCH-40 PVC PRE-PICK
['Geothermal(Heating,Cooling Soppy► ['Residential Water Supply Isinigle) ft. R is
D Industeal'Comntercial ['Residential Water Supply-t shared 1 Ii.CROUP
IRON TO MATERIAL EMPLACEMENT ME11100 A AMOUNT
Obligation 0 ft. 20 It. Portland tremie
NM-Water Sumils 1,cll:
111Moritonnt; ❑Recovers R. n. __,
Injection Well: R. R.
0 Aquifer Recharge ❑GroundwaterRecdiation 1�8ANRf¢AYIBLPrkk7C aOIBIBtaMP)nt
['Aquifer Storage and Rectum ❑Salittih Branca PROM TO MATE IAl. PMPI..er TMF\T MrTPKrn
22 ft. 29 R. Sand 2
❑Aquifer Test ❑Skimns:11er Drainage
R. R.
❑Experime tal Techaokge ❑Subsidence Comm!
2a.DRILLING LOG which Adana'sWets it wocewsan 1
CGeothemtallCloaedLoop) ❑Tracer now 1 To ORSC7dPTnr\.t.,.r.w.a.r...wu'nskPIK.VIM VW.elk.I
❑Geothermal IHeau ❑(l ng.Cooling Return) itter re\plain under#21 Remarks) 0 R. 15 R. sand
ft. ft.
4.Date Wrll(sl Completed: 7/26/24 Well IDaNw-31 R. ft.
5a.Wall Location: R. R, ' AUG 2 8 2424
Towngate Cleaners ft. R, ,
F,ac,My''OwnerNane Facdiry IDN(ifapplieabkl Ir.`.;:r-•;: t
R. R. D'f:C :l'fy
715 N Howe St., Southport, NC, 28691 R. ft.
Plnsuul]Addorss.Cit...mdZip -21.RLMARKS
Brunswick Bentonite seal from 20-22'
Omni Pmet htewidre:aion N.. INN I
5b.i.atitudc and Longitude in degreelfurisutnlsrcnnds or decimal degrees: 22.(.ertification•
Orwell ticidink:lat long rs+tdl"tekM) i'746d
53.923577 N 78.023376 W' ,,$'' / 8/8/2024
Signal'. ofCed Wall Contactor Date
6.hi(are)the wells): X PrrmaHrnt or L7Tempwran !h rigning ihu form.therein.certify rho the weil(rl war linen.)cwnytnreted or mrrordrrn,x
w•im 15.4 NCAC OTC.0100 or!SA NCAC OTC.0200 Well Conatnk'tion Sta18i,4'WWI rho;a
7.Is Ms a repair to an existing well: BYes or CNO ropy ofthi,record hat hens prnrufed to iho sell rn'wrr.
If"us repair,fili'.'', ,'-0.0 0, •mime torn tofurroark n tau/etpkaot rho lunar,.'f tar
repair under I2!remark.,Art nog..r..n the beet of thin fora 23.Site diagram or additional well details:
You may use the bock of this page to provide additional well site details or well
8.Number of welk earaslttaeted: 1 construction details. You Inas also attach addlhorral pages if necessary.
For mwlnple injerrh>n tN NMI-u-au',twrlplr 4,1114 ONLY MIA die woe ewa nortiow.wow nun
rafamittwre forma. SUBMITTAL INSTIJCTIONS
9.Total well depth below laud surface: 29 (f1.) 24a. For All Well*: Submit this font within :11 dams of completion of well
For mabllrlr wrlh leg ul!Ilep h.if dativevo le•.rowaple-t .00',ugl.'Of tulip construction to the follow-tw-
ill.Static water Itnel below tap of easing: (11.1 Division of Water Resources.Information Processing l nit.
If wow kw!a germ tiring.UM ." 1617 Mail Service['enter.Raleigh,N['27699-1617
II.Borehole diameter:3.75" tin.) 21b.for Injirtion Welly ONLY: In<kldtioi to sending the form to the address in
2aa aboe. also submit a copy of this form within '4)days of comp/moo of well
12.Well coestnK•twtn wmbd:DPT construction to the following.
tie.auger.rotan.cable.dime push.ele.l
DIYisinn of W'atrr Resources.llndergntwwd twjeclba Control Program.
FOR WATER SUPPLY WELLS ONLY: In36 Mail Non ice Crater.Raleigh.YC 27699-1636
13a Yield It[IHn1 Method of test: 24e.For Water Sopplt ..S.Injection Welk:
--- Also submit one cops of this form within tin dais of completion of
13b.Dhinfcetinn rope: Amount well construction to the counts health department of the county-where
constructed
Fenn GW-1 \oak Cambia Dgsunnrttt of Em,IOm1LIU and Natural Resources-Melon of WAKT Resataeus Revised Arent Nit-3