GW1-2021-01243_Well Construction - GW1_20210209

WELL CONSTRUCTION RECORD Fm lwkrW Use ON1Y
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Zeal% Thompson r To a ■D "
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4478A
NC Wen Coaarbf Caltakowe Nomba r To Tworwass I MA7g6AL
SAHDACCO Inc 0 f. 10, 1L 2' to SCH-40 PVC
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nor To I rA
L wen Cea "Voi"Ferry 0. 70002823 n. R. in
ba.U.mO.Je wrff prrwir fir.Co .Sao,.Von",.k*R10{r .I
0. 0. i►
3.WeR Un(cbwk wA mme):
Waco Supply eo: gum 7w . ,.. MA
10' Y. 20' 1L 2' LL .010 SCH-40 PVC
OAgficdluml OMmticipolPtblic
OGeahemW(Neriag,Cooh g Suppl)) OResideanrl Warr Sfppg(Aet*) L L 4
❑hkoffUNCOmmormlot OReAdenud Wafee SWphr(shmed) .t,o
OtNi 0 R 5' 0. Portland Ce Antaction
Nwwwwmw Supply Woo: IL
m OReeor R
tojKdn WON: IL IL
❑Agwtfer Rechnge OGMWWW far Reardiation
To MATKNOL&L "slim
OAgwfo Smmgemd Reroveq OSdtmry Berner 8' It 20' FL Filtered Sand 62
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OCnofheraol(Clad Loop) OTwea now To . . . wa,s .e.
OGemhtlnrl(How Soh Realm) 006o w0mem nadet 021 Remoh) 0 (L 20' 1L Brown Clay
It FL
4.0ae WAO)Campkkd: 1/26/2021 WdIIMMW-5
R. R
sa.WeR Laratiae: ti IL
Hamer USA Corp. 0. It
Fa:de.A3mav Name Fwedp nm(drppkcaekh w. w.
651 Michael Wylie Dr., Charlotte, NC, 28217 M. M.
Ph.rted Addax C*'awl Zp
Mecklenburg Sentonits seal from 5-8'
Cave) Platt WewAmmwm No 1m)
Sb.Lsdmdr and tawglm/t to degivegnimmotgo eoob or detlwl depvm ZL Certlflntlw:
Of-en resit.or hUkaa a Sum**)
N W 1/28/2021
SigaNwe ofCrndfod Wen Cawrwcp Dew
6.b fore)dw welksk Eftro mom or OTempanry gY e1 ,A./,roe f k ry .,y µay rk•W N.)Nm r.v rf,w,vvrd a arwdw r
,NA 13A NCAC O.'C VIW o.1 SA NCAC etc NOO wr8 C'wana,mw Smmdwd,and Her a
7.Is thb a etpdr to me atod.g wA: OYa or MNw YnpY old,,m,d 6..tr.w pov dm A.,.Nf,w.wr
NMh r a rrpwr.An cow fawN NY'U.aww+,lf•w mAw.,,nw lad rgdarn ON wwn,r wf Mr
..pawwr..#21,.,w.d,..n+eo.a..awf ora,4de,1.a. 23.Nor dlapotsoraddIeloodweNdetda:
You mry tee the bock of fhb pop to pmlide aftuttod wvil see damb or ad]
&Number of web earrueted: l cownfction dm&. You oq ddi aim suaeh oeoad pages tf owessmy.
w Fw,rwbP1,"wkv w as-.a,r••Oph seer ONLY.• iM MaM repw tlfrrr.�waa M
..bw .m./w , S iRMrlTAL INSTUCTIONe
!.Tad vdl depA below loMd MMgooe 20 r� Y �? (fL) 24a. For AN Wdlo: Soboof this fate aid" 30 dns of cotophsi a of weU
F.,.. kwk.0,hrwddrpm%,if do fr,wWk fB1M'and 7P ) comsocamtodestoRowiog-
1a.Stmb vela level helm top of essIM owDkWo etwater Between IwfarmofMn FrweesAK U.Y
lf.arr,Nrrl r.mNw,a,rmt.a,"•' - 1617 Mal Service Cato,Rddgb.NC 276WI617
11.nood0k dfaorlta:8.25• fin.) 24b.Far 6letrbw web ONLY: In addeion to teed0rg the form to riM addnao in
24m abort ales aubaoe a copy of tims lam whhm 30 dry of completion of evil
1L wA nwarnedfw meth@& 4.25. HSA cowshnchm to the folowfeg.
(re.cop.Vote).eobk&W Pal er:.l
Rhirbw wt Wworr Reawrets.Uwdrpwwaa lyselw Cans rmp...
FOR WATER SUPPLY WELLS ONLY: 163E Md Soviet Center,Raldslt,NC 276W16A
13a.VW(spm) Nabod of Not tat For Womer Sown A Isladom Web:
Abo subteen one copy of ft foot wobin 30 days of compkdon of
13b.RWofeedoa type: Amwort. well comov oclion to the coaay beehh dgmommt of the cower when
constructed
Fe w GW-1 Nonh Caluhr Dqumrr of F.meemer and Nanmd Remrav-Deana of Weer Rewwaw Sn ad A4W loll