GW1-2021-00684_Well Construction - GW1_20210203

WELL CONSTRUCTION RECORD Faun all Dkty"
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1.Well Cantratmr Information:
ILWATM�
Brian Ewing room im 885CUR 4
Wen Corium Name w• it
4240-B R• rL r
NC Wet Comncror CellifaatYla Newer FROM mAateTSR iRM'RIRm NATURAL
SARDACCO Inc 0 R 11' IL 1.5• iL NA Steel
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('oeaen Name
FROM 70 munmaa MA7rm1AL
L Wen CooetrMbR PC h. I/I0300399r 70002483 R. It.
Led YQ-XIb"Nr wrpp',mo fie.CYmrv.Sam.V---,.plain a.)
3.Well Vie(check well nark 97.
Water Spay Well- room I I 7t41109rip 1 1 MA
❑Agrlcilmnl ❑mmuIcpsolpublk 11' R. 19' m. 1.5• he MA MA Steel.
❑Geahermd(Meatutg•Cookng Sappiy') ❑Reademol Water Supply(sm*) R• L a
❑bdWUtlWComtmrc W ❑RembutW War Suppy(shwad) rROM 70 MA3Sm1AL I tmrm00&AMgtIRr
❑hen IL (L
Nea-W'ater Supply Welt
B a
OmDamonuff ❑Rant '
hiked"Well: IL IL
❑Agwlw Redmge ❑Gwudaa m Remnfiation
❑Aq®ftr Storage and Re vij, ❑Snli*y Barrier B. 4
❑ de Agnr TeM ❑Stomnrater Disease a IL
❑E�eciwmW TerMpbyim' ❑Snb90ace Cenhol
❑Ceodwrinal(Ckaed Loop) ❑Tn er FROM 10 NUMIU lrDlr .w.eR etc.
OGmubwnd Return) MOdw 4ciplam order 021 Remads) 0 a 19' R
IL rL
4.DSWWd(t)Compkmat: 1/15/21 Wen[DpA31
R. R
Sa.Well Lemrrtlyw IL rL
Jimadiation Management Service Company a IL - - -
FsrllnAle'eerNman FcBh WO(if gW16mbte) a IL -
2650 Shenandoah Ave., Charlotte, MC, 28205 m•
P*SkW Adknc Ck).ad Zip -
Mecklenburg 12710204 Temporary injection point through DPT tooling
Cna} Parcel ldeeltlWtlw No.(PIN)
Sk,Ladaie mail LemgIude in dgreNmW1MAlwaNr or datimal degrees: IL Certification: .
(a wd Itela oar htlkiW k aeM ftM
35.210533 N -80.001807 W Brian Ewing _ _ 1/27/2021
_ ,� ofCe:niBad WNl Ceatsrnr Der
[41are)LLe wdlpk ❑Mmanem K mTemperary 7_,j •' J
YI+iirrl'f+k lww.f Mrrb rrrtiJ�Mean nYi YrWal w+/Yrrrl rvwnlwxd a nroNe+n
.,AffA NCAC OTC.0100 w ISA NCAC 07C 021(10 Wra CrYom "Swed broad dewa
7.4 this a repair`an eadift Well: ❑Vn or LNe c'+pJ r'1dYe rrYoN Ao,be provided m At,Yrtl m,Tre
II+At+oarcpab,Ill frIbvlYe aw0,oawrart wjwiwrlarruMrydarn rbv,metre alrM
.rye Yndn rTf rcm+mrh mri•Y w m da bark
Jew/a 27.Site diaQam or mdrUamel well dens:
You may use the hack of(hie page to pmktde miklummil well she detaik or Well
A.Number of west eamatemeted: 2 cooMmction i1maib. Yon may also leach amboW poses if woo many.
For matn*rAfr Am w"-wain+'pph Yv?h ONLY Yvfh dw rowan eewaeotre.won.w CL)RMrITAI.INetT IC71pN¢
+Yewrwwlan+.
9.Total well depth fide land mrface: 19 tRl 24a. For As Wd4: Submit ties farm Within 30 days of coeylamm of well
Fnr"'rd+iplr wrllr tin nil depot ydi4Frcw IrraYyole-iP?M'm+d:®1(l0'1 Camruction to the fOlbwip
10.Sack water level bel a top of rating: (RI DAidem nf Water Raamrea,katermasaa rneeWus UmM,
y Yrw.kvef n above,.nYe.YY.. 1617 MA Service Career,Raleigh,NC 2709-1617
11.swank diamewr:2.5• {im.) M Fee Imiwdm Went ONLY: An addition to send"the form 10 the addnw in
24mabove. she submit a cops of this form Within 10 days Of completion of Well
iL Well ammrwd"medW& DRTVRN coronation m the fosowklg.
o c.male.man,cibk,&w pmmk cit)
Dh'kW of Wart.Reaanttea,UmderEanmd kajafYm Central rrerpum.
rM WATER SUTPLY WELLS ONLY: 16M Mel Strike Ceske,Raldgli,NC 27699-1636
13L VkW(ilm) Meebed of Wet 24c.For Water supply!hdood m Went:
Alto sdm* one oM of this form Within M daysofcrompietiounf
13b.Dkbf rdwi tyre--__- Ammet. __ wear compaction to the couay ham depwtmal of the county Where
Fo GW-t Noma Cooke,Depoemrm ofEm,ammat man Numu ReoM -Dn mom of war Rnaur6 RainedAp 2013
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