GW1--05032_Well Construction - GW1_20240828

WELL CONSTRUCTION RECORD For!truant Use ONLY.
The Forman be used for single or midtipk netts
1.Well Contractor Information:
Is.WAitRZON<S
Stefan Smith !NOAI , TO .. S i(•RIPtnry
Well Cotirxxx Name ft, ft.
ft, . fL
3576A
NC WellCoikiuclorCertifirytionNumber IS,OUTER CAS'\7C, furswI.e. ar�weAs1URI,INiRtif ants)
PROM To ! IN4MFTFR THI(t. M N1'sS tfTNIAI.
SAEDACCO 0 IL 1 30 n. 1 1" ie. SCH-40 PVC
Canpmp N.an( 1f.INNLR CASING OR RING(aaatrersal eh.ed•l.mp)
FROM TO M6.METER TRIC'G?E S MA1F441t1.
2.Well Conatrtrctioa Permit to R. R. in
l.ia an applit able writ permits as..County..Smae,Variarrr-t,tiye:$'at rtr.1 - - --
ft. ft. i e.
3.Well Use(cheek well Hack S(19. 'R[[N ,'
Water Supply Well: FROM TO IIAa1ETT1 5IntSlrr ' 1nmhNINS sIt trill 4l.
❑Agtrcuhltral I_IMunictpalrPlthloc 30 ft. 35 n. 3." es. .010 ,SCH-40 PVC PRE-PACK
❑Geothermal tHeating.Cooling Supply; I)Residential Water Supply(singlet R. ft a a
--
0 Industriak'Commercial I!Residential Water Supply b(skim-1) , FtsR,O GMROUT
to
M 1.1TRPil EMPLACEMENT METHOD a AMOUNT
❑ImFation 0 ft. 26 II. Portland tremie
Non-Water Supply Well: It. o.
Rhionitoring ❑Recovteq' , ____ _ .
Injection Well: n. fi.
O Aquifer Recharge [IGmundwatcr Renicdtationr 19.SANDA;RAVE L PACK tit icaMel_
!NMI to 114TERitl. FAIPI.A(T\tr.NTMFTROn
❑Aquifer Storage and Recovery OSaltni0 Hamer 28 ft, ; 35 A. Sand 2
0Aquifer Test OStonnss;ner Drainage -�
-
ft, ft
❑Expenmcntal Tcchnologv ❑Sdrsidencc Control -
Ill.DRILU\( LOG tatted additional facets if necesaan 1
❑Cteothemiul iC'Iosed Loops ❑Tracer FROM TO DF4('RReTIoN..ol.r.ha.dasw,sWn,kOpt. 'Mu ara.ek,i
❑Geoihennal IHeatiti/C'uoliu);Retunr ❑oilier tesplam under#21 Remarks) ; 0 R. 15 IL sand
ft. IL
♦.Date%News►Com completed: 7/26/24 Niel)IDsMW-28
P - I ft. It. I!I a .. -..,1 s.
5a.Well Location: r. ft. AUG Z S (0Z4
Towngate Cleaners ft, It,
Faction,OorerNome F,sitlm Ill.. applicable) i n ft.- Irito,a,,.. ''?•ra P7F.,=, • 1•
715 N Howe St., Southport, NC, 28641 FI Il. -
Plnstcal Address.Cits.and Zip l 21.REMARKS
Brunswick Bentonite seal from 26-28'
('ount. Parcel lduaffrcatioe No I PINT
i
5h.Latitude and Lnnglin &ill dkRtees.minutrslsernnds or decimal decrees: 22.('erdfieatLFR:
(i1 is,t:Iwld Orr Iat lnug is,rdl wwrul
53.922516 1► 78.025511 W .A5 f ± 8/8/2024
Stsmt of Cc Well Contractor Date
6.Ia tare)the waft* KIPevmaRent or Iemisaran
By Ai/ruing dqt forme,f hereby certify that the wrWxl wax fermi constructed im accordance
with 1514 NCAC 02C.0100 or 15A NCAC(DC.0200 Well C atarrwrion Stawhrrdt and that a
T.Ia this a repair to as mistime well: 21 Y cx or ❑No c'.5sy of thu record has berm prorrckd In Mr well('wiser.
1f*is is a repair,fill.or(n.on writenoOns tins information and r%plait,tlw aware of rise
repair ander 021 remarks'xrrtiarm or an the bark of Mix Java,. 23.Site diagram or additional well details:
You seta% use the back of this page to provide additional well site details or well
S.Number of wells eoRalrw'Kd: 1 construction details. You man also attach additional pages if trecessan.
For malttplr rnlerrh.ri or eion- mono iwpph wells ONLY with she SNOW canaa'actioa.t..a(on
caeutlirone bras. SUBMITTAL INSTIICTIONS_
9.Total well depth below land surface 35 (IL) 21a. Fur.All Wells: Submit this lions within ltl duns of completion of well
F.,,.nut,'per".•l1.If,r rll depth, •.•.r;,,:., ;":swtpfr-fOa700'arid 2k1001 confiinlcttflfl ton the following•
10.Static water lend bet n%top of casing: (U,) Division of Water Resources.information Processing Unit.
11 wn ter level u Obi, .• •: 1617 Mail Service Center,Rakig6,NC 27699-1617
I I.Borehole diameter:3.75" On.) 21b.For Inlectian W'el(1 ONLY: bi addition to sending the form to the address in
24a above. also submit a corn of this form within 30 days of completion of well
12.Well curet action method:DPT construction to the following-
(i.c.anger.titan.cable.direct push.de.)
Division of Water Resew-res.tIuule gnland'Medial Control Program.
FOR WATER SU PPI V WFI.IS ONLY: 1636 Mail Sen ice Center.Raleigh,NC 27699-1636
13a Yield(ItlMtl \tetrad .f n•.t 24c.For Water Snow 64 Injection Wells:
Also submit one(ropy of this font, nnallot in daysof completion of
136.Disinfection n p : 1nc.nmt_ well construction to the colmn health departmentof the counts where
cotistmcted
Fenn GW-I 'snob Carolina Deponnient of Eon immirm and Natural Resources-Dis'stun of Wafer Remus Re%used August 24I11