GW1--05031_Well Construction - GW1_20240828

WELL CONSTRUCTION RECORD For[monad UscONLY'
The form can tic nsd for sia•k or mldlip1e+tolls
1.Will Contractor Information:
••II.WATIRZONES
Stefan Smith FROM TO Ortit'RIPTN►N
Via C'onrutrr Nam: ft. ft,
3576A
fl, , n. .
NC Weil CoaractorCsniftcation Neither
r fl w( nr t..OI CAS, f raw kvsied%ego OR I IN t R l it alf
r140'1 7 to I DIRMTTFR Trn(A\T.A ' V%IT/011
SAEDACCO
~
0 rt. 30 ft. I1" h. SCH-40 PVC
( 101ietu Nang In.INNER4'.\SIN(:ORTlllllURINGlYtelb rn.. clowd-1..qo
F.4IO%I in oI smt It 11 ' Ifrlt I.\rs. ! .I.IINI11
2.Will Construction Permit/: II, (I. iw.
List all applicable wolf&waits fir.County,Saaa•,Variance.frOadio l rtr.t
ft. fl. is.
3.Well Use(check well owe • •
17.SCRU
M
Water Sapid!, %\ell: FROM TO nlsMr•lie 5tO151a- THI(1CNRSs j M\1111141.
CIAgn:ulnuai °MtloicipaUA/bhc 30 R. 35 It. 1" 'n, .010 SCH-40 PVC PRE-P#CK
if-leafing/Cooling C'ooliA 11. war
I'Geothermal( g, fqt Supply) °Residential)Voter Supply lsin�tc�
I I IndustriaUComntercial °Residential Water Su ptu(shla:I IN.(,Rot r
I-140M Ill MA TERCRI. EMPLACEMENT Ml111100 a AMOUNT
❑ItriFNmn 0 ft. 26 11. Portland tremie
Non-Water Supply Well:
XManitonng ❑Recovery ,
Injection Well: D. ft.
°AguiferRecharge ❑Cimunduaies Rentcdlatiun I'•.s.tsniatAVELPACKOfapplieable)
.,-14e1M TO vi;nava. FMPI.s4-FMr'TMrTHr/n
°Aquifer Storage and Recovery ❑Salinity Harrier 28 It 35 Cl. Sand 2
°Aquifer Test ❑Saom»t:ucr Drainage
O. ft.
DEspelinacnial Technology ❑Substdet►:c('mnml
20,DRILLING LOG tatlaeh additional dears if aecessanl
❑Geothermal ICluaed Loop) °Tracer FROM TO Drx'RIPTIt)N,toter,%ANe.e..,r.at'nw 4 npr.%Tier mire,rrr.1
❑Geothermal tHearng�'Coolieg Return) ❑Other Iexpiain Miler 0a21 Remarks' 0 ft 15 n. sand
rt. ft.
4.Date W'etl(s1 Completed: 7/26/24 Well meMt4-29
IL n.
5a.Will Lucati n: ft. ft. ,tl
Towngate Cleaners it. it.
1 IA
Factlrn Owner Nam_ Pallets IBM of applicablei H f. 'f
Qr/i`t.ii3Z4
715 N Howe St., Southport, NC, 28641 R. ft.
Pinsk/11 Address.Cin.and Zip it.REMARIES
Brunswick Bentonite seal from 26-28'
4,,n t Panes Iticolrflcaliun No.(PfN)
5h.Latitude and InnRtaik in deattesimiamtesf leosmds ale•decimal degree*: 22.Certification:
?it eon field.ma I:Wkn,is ndl"etcd)
53.922241 N 78.023140 W !' 7\/"s 8/8/2024
Sig � ofCe.fled Well Contractor Datc
6.la(are)the weff(sit E1Pcrmromew or DTemaMran Is riving Oki.JF.mv.I hrrd' certify that the 14w1Ns)our(Ferre)cuartnteted Re accarni once
with 154 NCAC 02C.0100 or 154 NCAC r)2C.0200 Well Coatstrue tine ord s void rho it
7.Is this a repair to an existing well: iaYe or ❑Nt► ropy of this record has*Ten provided to the well owner.
lfthis is a re/kar ill tsar loan....fir.,,VW,le Floe aaformwth+m wad rtpfaol tow*gore r'j rise
repair wader f7.1 remarks sr.7inra or on the hart of this fore 23.Site diagram or additional well details:
You may use the buck of this page to provide additional well site details or well
S.Number of weila comstrected: 1 construction details. You may also attach additional pages if le:CR ery.
Fla`multiple snjevrhan.o u.M.1Vellr,Wpftl Wells ONLY with the Mai*CONSlrxrrdow.via(,..,
submirone fimn. slIRMlTTAI.INSTUCTIONS
9.Total well depth below land mortice 35 (ttl 24a. For All Wells: Submit this fame within 10 days of completion of well
1,,,,,„ 11.1.;all,A.pr.,•.,.•;,:.,l,,.I.mrapf-ie'NMI dad 201001 constmction to the following
Ill.Static water keel heluw toll Of caving: (ft.! Division of Water Resources,Information Processing(nit.
if twice level u above commie.a•• - 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter.3.75" tin.) 21b.For lnketion Welb ONLY: In addition to sending the form to the address in
1.4aabme. also submit a copy of this form within z() days of completion of well
12.Well eursatroction method:DPT construction to the following.
t c:.0 ecr.rraa".c ihtc.direct push.ore.i
Division of Water Resources,UnderxnNrod Injection Control Program.
1,UR WA fEK SUPPLY WELLS ONLY: 1636 Mail Service Cenlcr.Rakish.NC 27699-1636
t3a Yidd(R1nn1 Method dtest 24e.For Water Sopply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
well const action to the county' department of departm of the county where
Ills.Disinfection 13Pe: Automat:
-- constructed
Fenn GW-t North Carolina Dcp(otnueru of Em laommel'and Natural Resources-Dn tsion of Water Resources Re.wed Av ist 2013