GW1-2021-00708_Well Construction - GW1_20210203

WELL CONSTRUCTION RECORD Vie ONLY + -
71d turmcaa ba tmof for sinpk«eshpe wear - . ..
1.Well Contrwetor Idorsudim-
Brian Boring ►"M pve(ll v
Wdi Conan«Name 0. It.
4240-B
NC WcH Cowmror CertSkamm Nenner -
FmM TD pO.M[l[R TBR'gi[Br.. MATER141.
SARDACCO Inc 0 IL 12- 1L 1.5• Is. N11 Steel
Ceepoay Nam
mu 70 auste7® 7MM70tt84 YA7OIAL
LWdi Cm,mior bin Pemkd: N10300399r 70002483 R. B, 4
Lis a Wh.N'wflperwit,a'.Cawee.Sim,raria«r,hfKPlvt
J.Well V r(elueck well mar).
Water Supply Well: M to BLOMM MAmuAL
❑Agricubunl ❑Mmcipsith"ic 12- M1 20- fL 1.5• Ia NA NA etael
❑Cttotbmmd(Hemirlg+Coding Supph) ❑Residemlid Water Sup*isvyle)
❑teOuMtrnUComrttercial ❑Rmidtwtid Water Sqo(shomd) FROM TO srA7cveA IQ1T L [aOrwC� aR1M0p AMOUNT❑hri ILIL
No Wnwr Supply Well:
Omemoomis ❑Itso.
lojecdon Wee:
0. 0.
❑AWdev Recharge 00mindwater Remedisaxt
❑Alpd er Storage a i llecmer) ❑Solidly owner 0. 0.
❑AQdfer Tom ❑rsums" rer Dwape 0. 0.
❑Eximmuctual Technology ❑Smbeidemce Control
❑Gmlhmol(Closed loop) ❑Tracy FROM N svetwvttDa mMwa
❑cepmemd a4vaWCoolift Remm) MOlheri I anduf2lRenmhs) a ti 20- a
ti It.
4.Date WeB(q Completed: 1/13/21 Well IDEAS ..
0. 0.
Ste.Well location: 0. !L
Remediation Management Service Company 0. 1L
F•cila)Oaaw Name FwihO Me(if appWAble)
0. 0.
2650 Shenandoah Ave., Charlotte, MC, 28205 w. 0.
Fysol AdJR Ciq.mud Zp
Mecklenburg 12710204 Temporary injection point through. DPT tooling
Comm) Paast laaatilkime No.(PIN)
5b.lotbode and Lomfdmde in degmnfmimaWmeb or dedad degrees
fa wep hN,ota ib7oig b sdBtRMI 22.Ceadllcadom:
35.210533 N -80.801887 �� x. 'w20 Brian Ewing 1/27/2021 _
5ipram ofCmdMd Well Camst« rim-
6-Is(oral for w'ell(&)- ❑P'ermmest or MTewporvey 1h rir^+•a Ala fame.+herrbv a"#r he ear xrlhal m Iwrml,vrartrr reel w mroNaorr
xrA+)A NCAC 02C.01M 11 11A NCAC MC 0200 Well C~w elan Swwbtrd,awl Am a
7.1s Ws a rcpa(r as m aiod well: ❑Yes or CNo e.,p,4tho rr,anih.hne pmrdrd m Ar
y rhu,r a mpwlr,fih twr ewww wll,,xw *r drfaarmara,w udraphw Ar nararr,q Mr
repair oven a21 mw.i,moron are,tlw bawl of fts fi. 23.Site dirgraor or additional well details:
You mo)'use the back of tho page to to m'ide additional well she dmis or ad]
L Number d wells mmmucat 1 rnmt action detain. You tm�also Busch additiond angry if mxto n_
For wWfiple mjecr4w ter arw-xwr epph veil,ONLY xvA rhr raav aanlraraaa.var,e w
•aeevr mr fo.w. SUBMITTAL INSTYICTIONS
f.Teal well depth bebiw land wrface: 20 (fL) 24s. For AN N'e(b: Submit dos fain wdbm W ins of mnpimm of well
Fin+why lr wlh h r oil Am A,i/Abimu/rwepir-iP:110'uM:F 1M-) OmWmnion to the(ownima
u.Stede water lead berw isp of evefeF (a) Dhislsa of Weer Resmorem Wemaden PnweubM UoM.
if xtlN,+rer+1,aa,wY ealMe YY.',•• 1617 Mall Service fester.RalripR.NC 27699-1617
11.Berebk diameter:I.5• (in.) 246.For lniecden Wells ONLY: in addition to sending the(Orin In the address in
24s aila'e. also submit a Copy Of this form within 10 dn's of completion of%ell
IL Well construction nxYML-DRIVEN CDOUMCbM m the folbwiag:
tie.mpr.imr).cable.Ana past eta.I
DF'Mteo of Wave Rewrres.Underground laJeedom Coverall Program,
FOR WATER SUPPLY WELLS ONLY: 16M Mel Service Center.Raleigh,NC 2769.1636
Us.Wild igpml Met6ad of own 24c.For Wier Sapdt A lokerkm Wd4:
Alto submh one copy of this (oral within M da)'sofcompdetomof
136.DWukedou type Amount: well coWrmtion to the comay bcakh drioutum s of the mum where
eorlMrmcied.
Form OP`-1 Nonh Cmhm Depmmis of Ewtwomat sad Nraeai Remims-Dnam of Wag Rtamrea RnnWA4paw2011