GW1-2021-01245_Well Construction - GW1_20210209

WELL CONSTRUCTION RECORD For lwero)UwONLY —�
The%mm be wed fa swat w wwk*k wells
1.Wdl Camtraemr ImfonmaNem:
XONU
Zach Thompson /ItOw to m "Irm"
Wen Comma Name m. N.
4478A rL a
NC We0 Cows catftmon Nankin rroar tw eNM{POI wAt[nNL
SABDACCO Inc 0 tL 10' IL 1' y, SCE-40 PVC
l'ortpm}Naaw
rqw VrM NrA aU7[mW.
2.Well CeeateanYka frerark a: 70002823 A. It a
' l�u,fl,ppiirwmr,rllprr+.ti,lie.Crvxr..Amr.4',riaa'r.eliraon rA.l
R
I.Wdl Use(ebeek wdl ear): 7 a No.
1.
Water Sapply Wd: w to NAMI 111(7(M M MATIMIAL
OAV%Vlmml Ol rp R 10' g. 20' R 1' is .010 SCE-40 PVC
OGmebimnl(Hating'Coolittg Suppy) QResidelnd Weer Supply(single) g• (L is
ObaktstrkUComttwtctal OResiaemal Water Suppy(shamd) roo m to au7gmw, I g11OlAL2MLtT
[3knptm h. IL
Nam-Warr Soppfy Well:
m. a
tgAlonim ❑Ram '
It. R
Q Agmfer Rechmtge QGmmdwater Remediatian
room rT
Qtikr Ap Storage and Ramer QSatinily Beattie 8' m. 20' IL Filtered Sand 02
❑Aquifer TCO OS(ormwarer Ommge It. It.
OEspcmmmaai TmhtmlM OSubudamm Comm[
QCcoibmmal rClowd Lpopt OTrxa raow m raw .mews dmw.
OGcolktmal(Heat oph Rtmmt EX)dm(EgAm under 021 Reemtls) 0 fL 20' IL Brown Clay
ft. (L
l.Dare We*s)Cowpkfed: 1/26/2021 WdIMOS-3 ft e.
Sa.WcU Lmodow: R R
Renner USA Corp. h, M
Fanlm-Owrcr No= FwdO WO(dappimbkt
651 Michael Wylie Dr., Charlotte, MC, 28217 pi h
Pl1.W Ad.k.CYn.and Zip $
Mecklenburg Temp well
Coven Prime idnmantoe No tPblt
3h.Lokm*and LamxMade in degneadolmafearseeoods eat dedYl dgpsec 22.CeriNkiWam:
ttf wca W&aaw[AID'S a wdRoewl
N W 1/28/2021
slg.mw ererntikd wen corwcw Dow
6.k rare)the well(ak QPeeuateme or MTO"Orary e,,itmn R A.fi�.,f AflPnl'1'rlhf IAd I/Y'YTlaY)eY,IXTJ sew,/,e['kYl N QibMieT
»nA!M NCAC OX MM„I SA NCAC OX ON)Wed O.mw ww SmeMrd,wd Mw,
7.k this a repair to r existing we*: QYa or MN* r.rrY,Hdu m-nM Mr,brew prnridM n,Ar„rt!„»over.
ffrni,rate,rpr21(r!l.ml Crier»w wr!!rwv,w rumq dw 1.A,e wdr ,urN,vrorc M,M
.riwi,e,ek,r_/.rxwrt,m-,,,.a.rw rw n,'e.(/'rAi,/e.,,. L.She dlmgrmar or adrWaal well daW:
You avt'use dM hack of dus page to pms'ide adbWNl weR mte douls or well
8.Number of weW ammo it 1 gamma tion deraik. You tnn Aso aaach additional pages it tt Yawn.
r.r+WApr„ wnwMw-»o rwt+h»rn,OA•Lr+Jma.mom c"wndrw:,,rN;'.ar
Yrbwr,mrJ.,w- 4 711MF7TAI.INST ICTIONC
9,Tad well depth 6eMw lead>•rfaca 20 hrdlk For AN Wens: Sabml das form within 30 orris of compMmn of wril
F",wW WI,»T8,Aa a0 d,,A,ifd*rno(rwwlw-+@'a)�wr.�link-r- L I{bnVmfaction to dtc followiog.
18.Siadr wmarr Mel bekw sap of eaaleC OL) Dkkba of Wow Remounts.Informed"Pneearlag Usk.
11+bxr kern u d,mrr,nu,R.e,r" 1617 Mall Santa Center.RaSeW NC 276WI617
11.Metiek diamehtr:2.25• lie) - - 24b.For lolmadom Welk ONLY: In addition to seeding the fo m to the addcea to
24m abm'e. also submit a copy of ibis form within %0 dns of conpktion of well
IL Wen eoaaeweft"no tbod: DPT cmwituction to the"lowhtg.
u e.sam.mmn.Oft.doom park M) Dh'Isloa of WatR Rteaaecaa.UadarywW lyiedaa Caatrd►agru.
FOR WATER SUPPLY WELLS ONLY: 1626 Mall Sen ke Cem W.Raklgb.NC 27699.16X
l3a Yk w(0m) Mnbod of use 24c For Water Sapid)At fa1[dhtw Welk:
Also submit ore copy of 1W form within 10 dm}'sof completion of
12k DhkJectloe Type: Ammmot: well mouraction to the comay health deponvtntl of eh coanh whoa:
eonnmceod
Four GWi NonbCmka orpnnntcw of Em,mnmca wd Nanwal Rmnwma Dnwnaof Wmc,Remros Maud At9JISVIi