GW1--05029_Well Construction - GW1_20240828

WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for sink or muliipk stells
1.Well Contractor Iflformatieu:
14.WATU ZONES
Stefan Smith PIOM TO DrsiatPT1O'
Wc11 Cnisntlof Name 1t. ft,
3576A ft R'
NC Well Contactor Certification Nanber 1S.OiUT=CASING(for muMi-cased walls)OI idNIR of mppcabk1
iROM TO DIiMTTFR 7111N1OTc5 ll MAT[RIAI
SAEDACCO 0 ft. 30 h. 1" ie. SCH-40 PVC
Campion Name ,stINNER SING ORTURIN`al ir`yeodium'.douM7 MATT) j
2.Well Construction Permit 11: ft. 1 ft. is.
Lu ufl applicable writ pennih(ie.County.Saar,Variance.GtaCNdt err.,
ft. ft. gin,
3.Weil l;+c(check wells*); t,.,(l(un
Viater Supply Well: MOO To ala71TTFR •,tartNI/I Ilia KIWIS f MATr*1al.
ClAgtruhtual 1_I1slurlicipalrArbllC 30 ft. 35 It. 1" in. .010 SCH-40 ' PVC PRE-PACK
1
OGeothemeollHealin .Cook s} I1Residential Water Supplytt, h. in.
g nR Supply) (singlet '
Oln [Residential Water Commcrcial 1[Residential Supply(shoed) Gittsl'1'
tom] . ni 0%Trill0 7OM,l-TMENTM111100astrn:NT
❑lmgation 0 n. 26 It. Portland tremie
Non-Water Supply Well: i— ft.
1@Monitoring °Reco ery ,
injection{Nell: h. n.
0 Aquifer Recharge °Groundwater Rcniediation 19.1ANDH.IIAVEL PACK(If apoRg11F)
roots To vs anatMI. rMFI.MI'Mr.\T Mr ruOn
❑Aquifer Sionigc and Ro mery °Salinity Barrier 28 ft. 35 ft. Sand 2
❑AquiferTcst ❑SronmsatcrDrainage
ft. ft.
❑[ npenmcntalTnhrtolorn DSabsidntcct'otrml ,.i ntttl.I1s10 LOG(attach.d thud steels if necessary t
DGeothennuil(Closed Loop t DTI-Jeer ,-u,1- i TO DeSSCRWr1O.baler.kaadaew.niilhnvk Opt.train are.elt.I
❑Geothermal iI lean nu+Cooling Return) °Other(explain under 1121 Retrwtt., 0 ft. 15 ft sand M_ ' , .
IL ft s ,
«� a
1.Date Wsll(vl Completed: 7/26/24 Weil meat-30 h. ft. C O )f�ZV(_)
Sa.Well Location: -- rt. rt. AUG 2 4
Towngate Cleaners f---.. ft. ft ►r•:{ :rr.b,i{s; `..' ii
Faciltlt'OuncrNam: FacilityION(ifappliablc h. h. • R
Qrr11.if.. ..9
715 N Howe St., Southport, NC, 28641 f1. fi.
Physical Addmcs-Chy.and Zip r 21.RUM(RIGS
Brunswick Bentonite seal from 26-28'
('aunt Parscl likuddtcaliuu No 1PI7t
ib.Latitude and Longitude in tiegrcealminutcs/sccnnds or decimal degree*: 22.Certiftcatifra:
(Hod]field,one Womb sufficient)
53.922241 N 78.023140 V4 A��kft 8/8/2024
Sigiul of Cc. Viet Con1170or Dale
6.In(ant the wellis): XIPermancnt 'Jr ]Temporary
Hs signing liar foram l hereby certify that the welhs0 was Iwrrr)ev annoyed itr accordance
wan 1 cA NCAC 02C,0100 or 154 NCAC friC.0200 Well COMMA:004 Saiadar4s and the:it
7.Is this a repair to an esfafi g well: 211Yea or ❑Ne cape njthir reesnf has hem panted to the will owner.
liahls is a Mpg,.fiill,Kat(ci's.ertf..eU7nw/i<M afforMouui:t<aei erpinat the(mare of the
repair under 02i remark,res7ma or on the back of this form. 23.Site diagram or additioeal well detaiia:
You may use the back of this page to provide additional well site details or well
8.Number of wells couaaructed: 1 cotlstmction details. You Inas also attach additional pages if necessary.
fur reainpk+nice root or n,Nt-,,tsar sapph wells ONLY with the MUM cauaacakuu.sow,110
+abmirone farm. SUBMITTAL[NSTUCTIONS
9.Taal well depth below laud sutrace 35 (p,l 24a. For AB Wells: Submit this form %%ohm 111 days of completion of%sell
For nod:wie wells list,all,kpth)ifdtffereo;(erampfr.1Eb2(10 and2BY1t5lf construction to the following
10.Static water Intl below top of eatthrg: (ft.) Division of Water Resources,Information Processing I nit.
If writer kvel is above rasing.ore"." 1617 Mall Service('enter,Raleigh,NC 2 7699-16 17
I I.Borehole diameter:3.75" (la,) 24b.For tnicetion WeIb ONLY: lit additwn to sending the form to the address in
24a abuse. also submit a copy of this form within 10 days of completion of tell
12.Well eoustraction method:DPT construction to the following.
ii c.auger.rears,cable.direct push.cr.
Division of Water Resources,Under gmuad Injection Control Program.
FOR WATER SUPPLY WFi.IS ONl II: 1 1634 Mail Service(eater.Raleigh,NC 27699-1636
1 :► l acid loom) 24e.For Water Somas&Injection Wells:3 7itihnd of n..r.
Also submit one cops of this form tsMori yo days of completion of
IJIr.Disinfection type Amount: well construction to the county heahh dcpamrfeat of the county where
coetmdtxl
Form GW-I Noah Cattalos Department of Ern unitertu and Natural Resources-Divssbn of Water Ruiolrces Res wed August Mr 11