GW1-2021-00668_Well Construction - GW1_20210203

WELL CONSTRUCTION RECORD Far lMcmolUu ONLI`
Tha farm ion u uud for single a naahpk wrna
1.Well Contractor Inforstardoa:
Brian lowing FROM TO 0CT(TMRIOT
Well Coumclm Nan R. f.
4240-B b. ft
NC Well Comrctor Ccnifrntion Numbcr O•oil=C
FROM TO I Dwmrren TBM'101131 I MAnlIRL
6ARDACCO Inc 0 R. 12' ft. 1.5• 4 NA steel
<'oapm)Nam1
FROM I DMWTBR I TTIM't(N13T I MATERIAL
2.Wdl CanstYaclloa Permit#: W10300399; 70002483 R. FL L.
(ia Wl appli,ufdr urlfMansns fi-r.Crwnrr..Sane Variamr,blftidol ra-.) R 4
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3.Well Use(hock well ow):
Witter Supply Wen: M TO Malawi fR$ TRICI( 13T MA` ::.
❑Agracultural ❑Mowkipid4 tic 12' R. 20' FL 1.5• hx I RA IRA Steel
OGeothemul(Haling Cooling Supph) ORes lelvial Water Supply(single) R fL is
❑Industrial/ComllMlcial OResidelRul Wafer Suppl(shared) IL
PROM W MAreew. RMtuccstltYT MEFROD t AMocmm
Olifignons R. fL
Not-Water Supply Well:
omonnoring ❑Roan a R.'
Wen: IL R.
OAquifer Recharge OGmwdwmer Remediation T
❑Aquifer Storage and Recover!) OSalinky Barrier runM IL ft.
.A MATRKMI. rMF Ta1RNT MY
❑Aquifer rest OSlormw'ma Drainage R. R.
❑Experimrnlal Technolopv OSubsidmcc Coritml
OGeolMlnel Closed y'
f Loop) OTear PROM TO 99WRlmOr a .tee rewrsra ram.
OGeothemal JileatioKooling Retain) ®Other lexplain under R21 Remark) 0 fL 20' R.
ti fL
4.Date Well(sl Completed: 1/14/21 Well MOAB
R. R.
Ste.Well Location: It It
Remediation Management service Company h A.
Fwfha Al.nr Nan Fxlin lDa Ofapplicabkl FL FL —
2650 Shenandoah Ave., Charlotte, RC, 28205 It 1L
Pl%sical Additw Oh.and Zip SLRRKAM
Mecklenburg 12710204 Temporary injection point through DPT tooling
(been last WsdlflJlbe No IFNI
5b.I.mibtde and laugkade is drgreeefminMteelteeaeds K decimal d(grm: 22.Certlfratloa:
1 dwell field.arehaMeg a softnel1
35.210533 N 00.801887 W Brian Ewing 1/27/2021
SigrRthrre of Cenhfaed Wdl Coat mew Dek
6.Is(aml the wtll(a)•. OPersanew or ®Temperaq
Br aiAnrny rwr hnm.1 Arrcln rrrrif.that rM xr7N.o war txrml,.xrnnn+rd m nrmdwm
x114 1 SA NC4C rl?('A1W m i U NCAC 62C 11200 WM Gmrtrw to.Sm",4s wid Awr o
7.is Ids a repair to an existing wen: Over or END ,T Ta x(rFu rrrnM♦m,1+rx pn>rMrd rn dr xril m,arr.
l/dris 1r n,rpuh,(0 rwr trwnx xrll �wsrinn riem urlamwre,n and r rpGluSrf4,�ur?�oldw Ol-�
rrpa;,wdr.a21.rxw.;cs.rr,::aw nr,w rsr n,aa 1 rfler/o.m. � - - 23.Site disgrRm or adtltloaal well details:
You testy use the beck of Ibis page to provide additional well site details or well
S.NRmbtr of wells mmtrwcted: 1 construction details. You Dory also attach additional pages if w essan.
For mWafdr Jji wA,A,x xa1-xarrr uwpN rWh ONLY mrA rFr afar rroaaperaw
J vT� CIIBRItTTAL INCTLICF10Ng
r.
9.Total well depth below lead surfacer 20 U (R,) 24a. Far AN Well Subaul this foam within 30 days of conwidion of well
Fir ma6iplr xrlfr lnrnd drprhr s/d�p"rrnu rrromplr Id20)'oM?W111Y1 conslnKlMnlolhelbllowilt;
is.Static water level below top of casing: (ft) Dhisloo*(We"Resources,laformaton Precessing Unit.
ll xaur Ir�d a nle,rr.a+wr ax"+ 1617 RIell Smite Center,Raleigh.NC 27699-1617
11.Borehole diameter.2.5• fin.) 24b.For Iniorthln Wells ONLY: In addition to sending Ilse ro ro the addf in
24aabme, also submit a cop) of this farm within 10 days of completion of well
I L Well mastractloa metbad: DRIVEN coulaniction to the following.
tic,water.raMu,cable dud posh.vier.r
Dlv'lslea of Water Researm,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Man Sm tee Center.Raleigh.NC 27699.1636
13a.Vidd(am) Method of test: 24c.For Water Sonph dR Injection Welk:
Also submit one Copy of this form within 10 do)'s of Corlple(iun of
13b.Disinfection QPc Aeronaut:- well construction to the coon" hith atmem of tie co u ly wore
. -
ea
constructed
Form GW-1 Noah Ch.D.yarasoeru of Em notmara ad Nxiond R soenrs-M was of Wee,Ret uts Revwcd AsgtR rllt