GW1-2021-00682_Well Construction - GW1_20210203

WELL CONSTRUCTION RECORD F«ImnalUwON1Y
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1.Well Contractor Information:
1 A
Brian awing ►IqM war eexrmx
Wen COoaacaa Name m. is.
ft. It
4240-B
NC Well CodlB[Ior Cenl&ipa Nambei
FWM TO NA.M[T[[ TKK'KN[m MATOLLAL
SARDACCO Inc 0 IL 11' It 1.5• ✓L NA Sisal
Cooarm)Was
rTmM To aLtmzm I T vc[as MA7[eLLL
2,W',U Censtawctke lermk*. Wl0300399; 70002483 tL K. la.
I"sU pp*,.bk wen jww.lit.Caws.Sear.Vwri ,.ki4rivi n.r
ft. I, 4
J.Well Use(checU well ear):
wake Supply well: M I VANKTIN a rrsin MA
❑Agicnhnall OMMLIPATImic 11' m. 19' R I.S. W. KA NA steal
❑ceotheanml diemiahgcbokng swot') ❑Resideaad Water Somh(siege) K' IL
❑hudusarkUComuawtcul ❑RemduF"Worm Sgply Ishwed) IL0110111 TO arA7[ah.rL [ aafmama AMtICNT
111nitimson K. K.
Noe-Water Swpply Well:
❑ ❑Recur
[eked=Well: d S.
❑Aquifer RecMrgc ❑Gaamdwater Reamidnign
❑Agdfer Sloaaleand Reco%tlr OSelhury easier
K. K.
❑Aquifer Teti ❑SIOrmwaler Dninege It IL
❑Expraossmal Tahoologi ❑sebodeem control
OGeotktmd(Closed L.00pl ❑Taxer YFX M To rlaxmmN r.arne .k.
❑Geahemml iHemaKoobw Rental) 1110ther icrtsisto uder a21 Remarks) 0 R 19' IL
It IL
4.Dak WeDtsl Compktd: 1/15/21 Wdr IDOBS
ti ti
So.Well Location: te It
Romediation Management Service Company IL K.
FmUlADwen Nman FwdoO IDN Ofapplkblel IL h.
2650 Shenandoah Ave., Charlotte, NC, 28205 R ft.
Mnssal Adlnac City.ad Zip
Mecklenburg 12710204 Temporary injection point through DPT tooling
COW" Pand idenmkarbn No.(PW)
Sb.Lad1Nt and Laegaldt Is deVwLhnhmaealmcmWs w dwimM degives; 22.Certification:
(if well field,ere WMall a adBckurl
35.210533 N -80.801687 W Brian Ewing 1/27/2021
SWo m orCcaLied wen Commem Dmr
a.ls(me)Me wellaY. ❑hrmaeN or IOTempenry " ^, 202
— A+ia�'r rlu krw./AraM rrrt Jr rM rAr nr/Yal ww Iwrnl cubit/rr'W in a'eordur.r
rod I51 NCAC 01C 0100 a I Sri NCAC 112f ti200 Wrl!G�nsmx'ww Smdurdr u,d rMr u
7.In Ab a repair to an existing wen: ❑Yes or KNn ern rywu rrcnd bur Nrrn Pmrdrd m rAr rNr rnnrr.
)Prix',n o repdr,fin err 4r•xn ern rvnnrwnrw wfurnrnww a d erpluw th,mmre'f rnr
"""ender Ill rrwwd.rn runarn A.be of O fare 23.Site diagram or addiWed writ detalc
You rob'use the bast of rise papa to pmeide ad3goml well site detals or welt
/.Nomber of wells nestrteted: I Construction Male. You dear also abash additional pages if aaxamn.
for wwlnpk ujrcrnw p new-xxwr u9pb xrll,ONLY xwh dr wmr emorwram, wr r an
.dwrr wr fear. SUBMFTTAL INMCTTONe
9.Trod well depth bete land nsrface 19 tfLl 24s. For Al Welk: Submit tin form wubm Hs days of mngAdm of well
For adnplr.0h ho an drpin rl dns..v rrrmnplr-i(r}pm'a d 2@ Iwo Contraction to she folbwing
10.Static water Ind btkw asp of eaaMF A) Dh'kba of Water Reaanrees.loform dism Prnendq Unit.
If xvrr krrl u rrnrm rrunr.nx"+ 1617 Mal Senior Caen.Raleigh,NC 276WIG17
11.Borehole diameter.)•5• (hL) M Far lek edom Welk ONLY: In addition to seeding the form In the address in
24aabos'e. also mibmu a copy of this font within 10 days of completion of well
12.Well omtrwtke ahetbedt DBIV[N construction so the folowieR-
ni e.aupg,aamay.cablt dime pet►meal
Oh Nine of Water Reawrcrs,u.derp.hand lyenw sense)Programs.
FOR WATER SUPPLY WEI.IS ONLY: 140%Mal Service Center.Raleigh,NC 27699-IU6
Ua.YkW On) Method of test: 24c.For Water Soeery R Inkakn Wells,
Alto solima ome ropy of this form within :10 days of completion of
13b.DWefeetlon type _ __. Answer: well construction Io the Como heahh dcpamtw of W many nt e Wheat
commcupd.
Farm GW-1 Plans Caohr D4mamcm of Est mmaem and Natural Remureer-Dwson of Wan Ratans Inn wed AVA2 N11)