GW1-2021-00681_Well Construction - GW1_20210203

WELL CONSTRUCTION RECORD FaimrmaltJw ONLY'
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I.well Contractor lnfortmatloe:
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Brian Swing mom to ptxltuqvN
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4240-B
NC Well Comactat Cenifiorioa Number IL Ov=CASING LumillawakdN
Yeah 7O alAatalaR TmCKNOW MATEMAL
SARDACCO Inc 0 IL 11' IL 1.5• W NA Steel
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2.W'dl CesKMCtioa Pcrmutl: N203003991 70002483 O. It. is.
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3.Well Use(tueckwell inrr.
Witter supply well: M To SWT a TmtT(1 MAttmAL
❑Agnicullmal OMmktipoVPllbllc 11t R 19, M. 1.5• 4 MA NA Steel
OGeothelntal(Hnating,Cooling Supply) OResidevi dal Water Supply(siogle) (tit a, )a
136dlWriaUComrranctal OResidennal Water Smppb'(shmed) tLclbwr
room so MATTRW. I IMPIAC1011INT11117111110041 AMOUNT.
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Now-water swppb•weft:
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❑Aquifer Recharge OCaomldwater Remediahon
❑Aquifer Storage and Recovery ❑Salinily Barrier FROM .T
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❑Agoi kr Test ❑Slonarover Drainage R A
OExperimerml Twharlogn OSubmicnce Control
OGemhemml(Closed Loop) OTmeer FROM I TO ItIpC10►IMIS r.w owe► ea.
OCeothemed(Head ook Return) ®Other lexpim Imder o21 Remarks) 0 (. 19. ti
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4.Datewei(s)Campkud: 1/15/21 WeUlD#B9
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Sa Well Location: IL it.
Remediation Management Bervica Company a. FL
FncdayATsmm Nome Faeitt)WN(dapplicaak) fL R
2650 Shenandoah Ave., Charlotte, MC, 28205 R IL
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Mecklenburg 12710204 Temporary injection point through DPT tooling
(-aws) Pat t IdeaomcNiON No.(PRO
Sb•Lado*and Longitude in degramfodu tesheawds wr decimal degracc 22.Certification:
to an hid,oust wit log fa uok.00
35.210533 N, -60.801887 W Brian Ewing 11//27/2021
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6.Is(are)the well(a)* oPermreve or ®Temporary { 8,,i3mimx My ma,,t lw,,M r,rriJr Ma th,»wIko a* .W fm*,aN ,r
y 2021 xiA 154 NCAC OIC.01Mw lG NCAC 02C 02M Wrll Cras+nw rim!Mdarde unArin+n
7.Is this a repair to an voistiq weft: Oyes at tRNo`J - ,•)m,ofrhi+rrrnMAn..lwew Pmridrd stem»ell mvnrr.
llMi,n a repair,felt aw Amax*xwO,,*,rrw'.ew afomavri,*a d'Nium.Th,Mr."f Mr
RI m,wrAx,nv.*a,*M,h.A,l tAi,/,r*. 23.Site diagram or additional well devils:
You may use dw bad of till page to provide additional well sue details or well
S.Number of wells mwstrresN: 1 construction details. You at"also amid additlaoal pages if necessary.
For*.rail,i.J.rhm w m*-»wr u,,ph xvf s ONLY xvrA Ow samr eaves fiaa wm,vw
,aN*ir.forty. SURMITTAL INSTUCTIONC
9.Tutalwell depth below tesd aided: 19 (R.) 24s. For All Wrua: Submit this form within TO tans of completion of well
h,,Mho,xwrtsric alidepAr i02M',wd 7fa IWI construction to the following
If.Statle water level below nap of easing: (ft) Dhkion of Water Rewortea Information hareseleg Usk.
I/.uwr kr,I u aaar,..st.r..r"," 1617 Mail Sender Cemor.Raleigh,NC 27699-1617
11.Bereaok diameter:i•5 IhLI 24b.For IniQlbw Welk ONLY: In addition to sea&*the form to the address in
24a aim e. also submit a copy of this form within 10 dens of competion of well
12.Well construction aMtbs : DRIVEN constm000n to the following.
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Dakloe of Wmer Retawrcea Uwderpwand[ejection Control Program.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Senke Center,Raleigh,NC 27699.16M
Ira Ykld(am) Method of tea: 21t.For Waste Supply E Injection Welk:
Also submit one copy of the fomf within 10 days of completion of
13b.DiYofMien type: Amount: well construction to the coon' health depanmem of the sonny where
constructed.
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