GW1-2021-00699_Well Construction - GW1_20210203

WELL CONSTRUCTION RECORD Fa Imemal woVu
Tho km Aa 6c used for nrwk or muaipk ue0s
I.Well Cantrartor information:
Brian Ewing IIOM 10 Rtx('tlrrxaN
Well rorerxwr Nam t. i It.
4240-8 8' h
NC Wcll Cowxtor Cen)fir Mfi NmrEcr 16 OUTER MWA
FROM TO eIAM[T[R 7NPCICN[SS MAT[t141-
SAE)ACCO Inc 0 rL 1 12, h. 1.So to I NA Steel
import Name 16.DWNQ
TROM I TO I OWMIUR TRIMNESS MAT[RLAL
L Well Coostrostion Permh a: NI03003991 70002483 R, ft. Y. ,
Litoft xpplti xnlr urlf prmdi fie Cwnn.Sxur.l'xrixp'r.Ifformntn,.) Is. IL4
3.Well Use(chab well orw): T .
Water Supply Wed: ►ROM To I DUM[T[t I MAM I Tw1(TCNr35 I MAmNAL.
❑Ag/Kultural OmunkipeVPublic 121 h 20' h 1.5- in NA RA Steel
OCCothermsl IHealilgCooling Sul I OResiden ial Water S1ypk(single) rL h m
❑bdustria6`Commercial OResideniil Wairr Styph(shared) IS.
raom TO M,ST[RLAL [MPLACL74LNTM[ MAAMOt'NT
Ohngotion h 8.
Non-Waer Supply Well:
h At.❑Mouton ❑Ram
Injection IL rL
❑Aquifer Recharge OCwourtdwaler ReelediAlon MSANDAMAVKLPA
❑Agmkr Storage and R=oien ❑salinq'v Butler FtOM Fri. TIP h MA Kim. [MFI.A(1111[NT MR
11109
❑Agnikr Test Oslo..... Drainage n. n.
❑Espeiimnwal Techmbjfs' ❑Sibsideae Costal
OGLwthenoal ICloud Loop) OTracer »rhim rb ffn IROM To way.e6 r,,,w.
OGeothemmal(HeminKooling Raum) ®Other lexplasm under all Remai►s) 0 It. 201 h.
It. fl.
4.Date WrRlsl Compkted: 1/13/21 Well IDS B14
h h
So.Well tacatbn: h h
Remediation Management Service Company h h
Fecdn.Vantt None FxOes lDr(if appacabk) —h it
2650 Shenandoah Ave., Charlotte, NC, 28205 h rL
PhlSics AdfesL Ctn.and Zp 24
Mecklenburg 12710204 Temporary injection point through DPT 1:ooling
Cana) P. ldeatakaba Nu (PNNI
Sb.1AMode and Lowiliwrde in degreesfnirmtalMsonds or drebnal degrees: 22.Cattl'ritlot: . .
Of welt(kid,ore htforg h suRkwa)
35.210533 N -80.801887 W Brian Ewing 1/27/2021
S,g=wm of Ccnrfwd We0 Conocior Dow
6.1slareithewelllsk OPcrmanent or ZTemperary J 2021
.. B. ..Tmnc chit lornr./hrrefn rrnN rhm dr.r/h.,)nvr iwrml..nu'rrx,rW m un.Nm,r
r,A 154 NfCAC OTC r)1(r).v I SA NCAC 02(' O7(M)Well('unn.w ran Sw d...1,,, rd,Amx
7.Is this a repair to an existing well: OYa or ZNo ..rr. .nf h,n nrm vxo nsd m)hr.r11 ovn.•.
I/M.+„n rrM+lr.!lL.xr tm,nn v1L•n,u,r tore rn/<mnvrtxw.rd rydum rhr ndnrr of rhr
..ip;r x,sdrr F'1 rrx,xrt,,r.,:.m or.m rhr a,xt„r rni+era 23.She diagram or additional well dnaRs:
You Dan We the back Of This page to provide additional well site details Or well
S.Number of welh constructed: I c'Ona INschall 6CMIS. You may 260 ARA h additional pages if oeressan.
/�.,mdrrplr infer rxM.x m.n..nrr,,wy4, .rI),OA'LI'nmh rhr wrier raaiwaraew ,.w.n.
,xMnn av f".' SURMITTAL IINSTU(TI41NS
9.Taal well depth below land wirfan: 20 Ihl 24a For AN K'tlh: $idlnal this form within yo days of conviction of well
For redxMr.rN,h,r uN drrxn.gegfrrrn))r,nm),rr- r@'!A) xM,q l,r)') comaniction to lbc folbwing-
10.Stalk water Inel below rap of casing: Al Minion of Water Stesaurra,information Processing Unit.
I!n.,a,lrsr!eurinnr rxuxr x,r' 1617 MAR Seri let Canter.Raleigh.NC 276"-1617
11.Ratchek dinarrom I.5' Thal 24b.For Infective Welk ONLY: In addition to sending the form to the address in
24aaboic. also submit a copy of this form within 10 days of crompletlon of well
12.Well construction mabod: DRIVEN comtnicorin to the following.
o c eager.roan.Able.dnea pink ce i
Dly'hbn of Water Rtsontees,Underground Injection Control Program,
FOR WATER SUPPLY WELTS ONLY: 16A NUN Sm ke Center.Raleigh.NC 27699.16]6
13a Vidd Win) Method of test 24c.For Water Supply A,Injection Wells:
Also submit ore copy of this form within iD day s of cromplaion of
13b.Disinfection type: _ Annual: well cutoaunbW to the Camay bmhh dcysnmcm of the curmn where
constructed
Form GW-1 N,)nA Cmlup[kpannem of Fm)mimeia ad NiNal R.Youwes DN one o!wain 0.ewces Re,wed At®at NNy