GW1-2021-00677_Well Construction - GW1_20210203

WELL CONSTRUCTION RECORD For lmenmlUvONLY
The fare!as be sad fill sapk ar eW yk wens
1.Wail Costrscter Idermatles:
Brian 6alag FWM lO apMllrPtq%
Wen C4MMev Nam rL R
R 4240-B ti.
NC Well Comraclor Candice on Number FROMTO MAN" Too"C"8S MA7rmAL
SARDACCO Inc - Ill ft 1.5• Ia. NA Steel
lk
(bmpary Nagle
TO MAMFTTR TmlWMSS MATTRLAL
L WeR Gms"Whom Prank#- NI0300399; 70002483 R. M.
4a a8 gprirablr%tBprmlih lie.Ca•r).San.Varmw'r.flyQbi rA'.I
Wen Use(cbnk well on):
sapply Wel. FROM 7o InAMRTsaI Skit MATERIAL
❑Agsiculaml ❑MmicipdMblic III tL 191 It 1.5• to NA NA Steel
❑Geahermd MC1111ag,Codiog Snrpph) ❑Resfdemol Water Sn4ply(sioge) IL R 1a
❑IodMtiolrComtmcul ❑Residemai Waver Sappy(abm9dl /ROM To MATRRW. [sOIA(Lm1T MFMOD a AMOUNT
13hrionion It h.
NorWater Sappy WeN:
R a
ElMossoming ❑Recur
It a
❑Agoikr Rechmge ❑Glow dswer Remediagn
TO MATKU"
v
❑Agntifer Slaage and ReMsep� Oaiip Stiy Bomaw. ti
❑Agaiftr TCN Osmrmester Uarge fV It.
❑Espenmmml Tacbl o ❑SebsadeoM Coatml
❑Georherorl(Cbm4d Loop) DTneer FROM 7O aY[LPIIO% wwmet Alamo
❑C"*mmel Remm) WiDdlerjaphoovidettill RemaRa) 0 IL 19. IL
ti. R
4.Date WeD(s)Completed: 1/24/21 wdllDdBl3
ti. ti
5a.Well Location: (L IL
Remediatim Management Service Company ft. 0.
Fwdq•Oaar Nam Fwd*11M(ITspplkable) rL n.
2650 Shenandoah Ave., Charlotte, NC, 28205 lL IL -
P*sKW Addm,&Cey-peel ZO
Mecklenburg 12710204 Temporary injection point through DPT tooling
Conan Parcel Idesbikalae No.(PMt
Sb.L.admile sod Lonldimde is degsa9mhmteslreemods or de1:WI dlgrom 2L Certlllesdw:
(if-to new mm h0we a ei(ft")
35.210533 p( '-80.801887 v r' r(�21 . Brian Ewing 1/27/2021 .
Siglaaala ofC4%UW Wdl ComanM Dam
d.4(slut de wd1aY. Drefinemeat or nTeagoruy sh nr anp du fi• .14e.ras rm',v aim air.rIiw%a,I.rnl saal.a.w m e.a%•s.
reAISANCACO2COIW,.IfANCACICC1)..IMW,Ue'Wnf "Sw"wdianddwIa
7.b tbb a repair to in eaisliall aeR: Dyes or CN• „Ps•Jdi..karo Ma are.pmvdrdwIM..n menu..
IJAt,u o repair,Jill..d.,.n wvU,~I11.M.Ylfbn aml ud,wdW.rw n W, 41Ar
"P. d"r_l,rma.as s.sum.a.o,asr Aare Idi.k.m. 23.Sate diag our or addidemY well detats:
You mg ase the link of dlis pogo to li m'We additiond wail uw deuib a aell
R Nuber of weds contracted: 1 construction deoib. You on)aia aaoch it"Ooeal pegs if no="*.
FW edaldr,n*,kn W n!N-NYWI ap,wVill ONLY MVIA!Ar YM faenreMae.W W,411
,.b , f _ 5111111111TTAL INaTUMONe
9.Tetpl well depeb bei m Isad oarface: 19 (8L1 24s. For AN Wel6: Submit des fam within 30 dms of Mmpkliam of well
for e,diiplr wrfs l"I n1I&po,fdgi r..;fir aw'-ip2M uM 20014"l OMMUI lien 10 the fOR e"1116
1s.Slade aster Ind beta rP of easMC ID.1 Dit blen of Water Resources.IsfOnmaMem Processing Upl4
If se,kvrl b a6uve,naxr.r '." 1617 Mall Service Ceswer,RnK*NC 276f9-1617
11.Bare'bote diameter:!•5• (hLl 24b.Far Inkedime Wells ONLY: In addition to seeding the ftim to the address in
24a abbe. aim submit a Mph of this form within 10 days Of conviction of well
IL Wel construction awbed:DRIVEN commence to the f0RMltmga
to a.am.mon.asblc durm peal or
DFYW of Water Reesrets,UNerpesed f./reMem ceatrpl rI.Q..,
FOR WATER SUPPLY WELLS ONLY. 16M Mai Service Crater.R&WZ16 NC 2789-1616
l3a Yfdd(Rpm! Method of Tell: 24c.For Water Supply•Inlxti n Wehr
Alto submit one copy of this form aphis 11) days of comodion Of
I3b.Dishif"em ypa_ Annual: evil conamcom to the comb beaph depnmwt of M M e msy When
Mnnalcled
FormOW-I Nonb Camium fllpanmcm otFmmlmcn ae Nmmal Rcmmam-DhemolWm Redrors Rneod Anym2o11