MO-7037_27784_CA_WSW_20151120_Site Visit looking for WSWs

Site Name: I� Incident Number: 07P
County: UST number:
Region: GPS Coordinates: N
Site Information Checklist
Facility Information:
Operating facility? Yes No
Valid UST permit? Yes No
Number of tanks: Yes No
Site map/well map verified (if no, explain discrepancies in comments section)? Yes No
Any visible spills/leaks (if -yes, explain in comments section)? Yes No
Any visible water supply wells? Yes No If yes, distance to closest (ft.)?
Remediation System(s) Information:
System 1
System 2
System 3
System type?
Fully installed?
Yes No
Yes No
Yes No
Operating?
Yes No
Yes No
Yes No
Free product present (verified)?
Yes No
Yes No
Yes No
RP/consultant/other on site?
Name of RP:
Name of consultant:
Name of Other:
res Taken?
Location of photos:
me spent on site (hrs):
Yes No
Yes No
Company:
Company:
Company:
W
ments:
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Mecklenburg County Groundwater and Wastewater Services
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http://maps. co.mecklenburg.ne.us/website/WellInformationSystem/wis. aspx
1/13/2006

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Page I of 1
MECKLENBURG COUNTY
Well Information System
LEGEND
Parcels -Well
View
®
Dal hSAeandWell
DLandfill
®
Publicl4oll
®
Contaminalwn Site
PrrvatoWell
Jurisdictions
Charlotte
Cornelius
® Davidson
OI I u niersvilin
Matthews
Mocklonburg
Mini Hill
Pineville
Stalling
The information provided by this program is compiled from recorded deeds, plats, tax maps, surveys, elections information, and other
public records and data. Users of this map data are hereby notified that the aforementioned public primary information sources should
be consulted for verification of the information. Mecklenburg County and its mapping contractors assume no legal responsibility for the
information contained herein.
http://maps.co.mecklenburg.nc.us/website/Wel.../alsService_NTGISNET1335212963875.pn 8/10/2005