GW1-2021-00664_Well Construction - GW1_20210203

WELL CONSTRUCTION RECORD For Imemel Use ONLY
This Form on,be used for siml:or mAyk wvUs
1.well Contractor Warranties:
A
Brian Roving FROM R R
we0 Corrmclor Nana R. a
4240-B a a
NC Well Coo rsawr Condboans Neater
Mom to oKML1TR 79R'geaw MATTYAL
SARDACCO Inc 0 a 12' IL 1.5• ia, NA Steel
(ommm)Name
FROM 70 atAtatTaa 7wICKNaRt MAITRML
L Wen Coast net 0permit P. N10300399; 70002483 11. It. 4
1"d1 npp6rebk erd promo,Fie.Cw ..,ram.Yo6awc kJOKAM eA-.1
a a :.
3.Well Use(cluck well use),. IMECIRM
Water Supply Well: FROM 1 TO - MA AL
OAVocultmal OMWKVOVPublic 12r It 20- a 1.5• to NA NA Steel
OGeoBemsnl(HeRiRS)CooBlg Supply) OResi nSW Water Supply(single) a a hs.
OhmduwlsUCormmcial ORwider®el Water SggA'IshMadl 1111.
FROM TO MATOIAL RMnA[LrmeT MirMW&AIMMWF
Oirrimmem It. a
No■-War Supply Well:
R. a
OMmdlo' Opcco%vvy
la)ecdour Well:
a a
❑Aquifer Recharge OGrou■dwmer Remedialion
❑Aquifer fAmW and Rxmery I nstintly Barrier FROM a a
❑Aquifer Tess OStormwster Drainage
a a
OExperimm"I Twimolm OSubsifmce Control Liaddim
OGOOIheroMi(Closed loop) OTnar FROM To DUCWnnx..., �.-. . .vase eon.
OGeothemW Return) MOdw(e*am under 421 Remarks) 0 It. 201 a
IL a
!.Dale Wedb)Compk d: 1/13/21 Wdl[)gAl2
Is. Or.
5o.wen location: It It.
Romediation Management Service Company a a
Fwdk])weer Nam Fwasy nx ldrppkbki It. Is.
2650 Shenandoah Ave., Charlotte, MC, 28205
Physical Addo:sc C*.and Zip
Mecklenburg 12710204 Temporaryinjection point through DPT tooling
('oeaw PMer IdernMyaa No.(PM)
Sb.Lsdhde and Longitude to dp(rem/ml whefaxonds or deehwal degree: 22.Certification:
ae»en ACK ort[aim is wtfkkr) R r�g�
35.210533 N -80.801887 W Bran EWing 1/27/2021
Slgmra,e ofCMdiod well Crrrmswr fine
6.h(are)Me wes(a): OPermseeet or ETemporarY' n w41J ,r rlar John.1 hereby wniJr rim aw wrlde!ear I wrrtl avnsrrrrreA In«ro,.m...
1n�`'3,G NCAC 02C.01d0 mr 1 fA NCAC 02C.0200 Wed Co rm we Sma mfi u,od AFm o
7.Is this a repair to an eds"ll well: L]Yev or ®No r,ps ofdis rrcvwd Aos here pmenkAmrhr,m1!nnwr.
ryrh/a u a mpdr,fid oar 6rr,ne wed<oevrrmrtem arJorneam.ard repfum rAr,mare olrAr
rcptirmdrr I11 re,vark+m'rmn a m r6e bat.nJmiv farm. 23.Site dlspww Or sddhlsnd well deeds:
Yon may use the bark of the page 10 prm'ide addammal well sae details or well
0.Number of wells mom rock l construction details. Yon may also assets addition pages if necessary.
For mdnpk hq", n w nw-nnre,upph welly ONLY mrh Ow s mr a vvdm.von,.
xahmo war futon. SURMtTTAL INCTUCTTONC
0.Total well depth Into Rood surface: 20 (a) 24a. For AN Wells: Submit this form wsMs 30 days of compkeion of well
Fwmdr(pk wad,lie nOdrph,bdlQercnr lermapk-3F200'and 2F/Orl C01311WOOD m the Winning
10.State war kvd below top sf easing: lal 111%'lsbe of Water Resmurres,Idoroatiaw P..aar.g Unit.
If wife keel k arbuve,nswe.nor '.' 1617 Mag Sen'her Carter,Rakish.NC 276WI617
11.Rmriole diameter 1.5' Ow.) 246.For IakerMa Wells ONLY: In addition to awning the form to the amWmew in
24m abm'e. also wbmil a cops of this form within 30 days of completion of well
IL Wed maatrrtM OghM: DRIVEN CdWNCIbn to the following.
lie,auger,rang,eabk deep pask mc.l
DIs'Ialsw of war Resonrees,Uaderpv■eel IyeefW ca■tmI Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Sen'ke Center.Raleidr,NC 276WI636
lk"a Was) Atc"d M toss 24c.For Wow Sutvdv k lutoelism Welk:
Also submit one copy of the form within 30 days of completion of
13►.OWdectlee(7FC.___.—_____.... Aa nt:---- — well construction to she com■y health departmma of the cwmry where
corAusctod
Form GW 1 Noah Camlew Depmnrren of Eavrmmovs and Nrwal Romaaes-Der ate of Wm,Restarts Re,aed Asym 2011