GW1-2021-00665_Well Construction - GW1_20210203

WELL CONSTRUCTION RECORD For lmnml Uw ONLY
The Fond on a sad fa croak or ewppk wens
1.Well Ci ntrarier lmformadon:
t<
Brian Ewing Rom TO DCKVA' oN
well common Nam h h
4240-B R. R
NC Wen Comasor Condkown Nw*a LMK
rROM 70 DN.MLI[t TIIR7aRm MATERIAL
SAEDACCO Inc 0 a 11' IL 1.5• lot NA. Steal
Coevaq NAM
FROM 70 DUME'Ra TNIr1NM I MATTRf.L
2.We"Ceawtrtuka Perish k NI03003991 70002483 a. b. 4
lie a6 appAr.Ab xvUpn.vh(inns Cmrrvr.slow.Yarionre,drp'ecam rn'.1
R R 4
3.Wig Use(cbalcwell war).
Water supply Well: niou To I
.,sun sin I itse m, etATTnwL
OAgicukmDl OMmictpol% ec 11- R 19- h 1.5• is I NA NA eceei
OGeolliennd(Heatiagkooliog Supply) OResidehirl Wiser Supply(cings) h R is
❑bukutruwcomnwmml OReeidonal waver Supply(shawl) FROM 70 MArzaw. [IPIACYMAVT imNaD a AMmmr
Ob.i R a
Non.Waar SEP*well:
a R
OMwwo• OR=mvq'
bijectlon Wen:
R R
OAile fer Recharge OGna dwater Remediaion
0Agw1ix Seongeand Reco%iM OSRIiaily Banner R TO h
❑Ayoifer Test OSlormwatrr DFamele R R
OE)penmwnal Tochnobhs• OSubsidrnce Control IL
OGeaheanal(Closed Lisp) OTmca RON 10 DaartmTDrwn.h wwmit . tarns. .
OGeothusal(HousWCoolitill Retain) ®Other under a21 Remarks) 0 R 19- a
a h
4.Date Weals)Completed: 1/13/21 Wd1(DAA3
R a
So.Wen Location: a ft
Remediation Managenant Service Company It. a
Facilk Oww Nwoe Fecdin Ina(if applimbkl
a R
2650 Shenandoah Ave., Charlotte, NC, 28205 m M.
Phgsicd Address.Ciq.ad Z1p
Mecklenburg 12710204 Temporary injection point through DPT tooling
COMO Pmd Idemmarba No,(PM)
sk Caddie and Langwtde in degRealmlontedsepwds or deeioul dtgseest 22.Certification:
Woom meld,ow hsnogk so(lekwl
35.27.0533 N _60.801887 W Brian. Ewing 1/27/2021
Sipmest ofCedified Well Cession Due . .
6.Islare)thewe0(sk OPenmaneat or Ememporaq'
r.G Y G ��� B.ngrw+F rAv jonn,1100e 5A AI rAC nr Wko
0200 xn.l ten/a ava w W in o,,d AW.r
1 � xidr!SA NCAC OIC.UIM m I fA NCAC 2rC' O:M N'eU C'rwrnrean Swwdordr avid u6vr n
7.to this a repair to an esidaR weB: OYa or LND ,ofn ofPW Yard Ana tore po,'wkwi m Mr%,It w,
/fAbu araper,jUl list enwe.elh w.mko.m/omwrro..wd rwkm Me.mare,,f Ow
'Onu mrdr.nl,rmn.A,mist ar rm A,Ix.t of ma/,,..,. 23.She dlograns or additional well detaft
You cony use the back of ids page to pm%ide additional well sue duals or well
S.Number of wells constructed: 1 construction drunk. You run'also one*additional pop if soce nusi
Fnr mrddpk mjrahm w ism-xwr mppA 4r11,ONLY xdrA Ov raw,onsomrke.w.,rise
r.pwu err his.. c RN1TrTA INST iCTIONS
9.Ted well depth below land surface 19 (R.) 24s. For AS Wells: Submit dos towns wathio 30 days of completion of well
Fw m.hW,xdh ho all dram,t/dtffrmo l,.,o pk-i@_UU'u.d 2w Imrl Consouctiwr to the followig:
10.State weer keel below'sap of"Wee IR.1 Dhision of Weer Raaurea,lafos'a slap Processing UDR.
lf.uwr Mel u.bore raver..rr"s" 1617 MAN Sersiee Center,Retell*NC 276WI617
11.Borehole dhwaer:l•5• (hens) 24b.For lwkrstow Welk ONLY: In addition to sending the form to the address in
24a abos'e. also submit a copy Of this lots, %shin 30 dnT of coutilulon of well
IL Well consented"mabod: DRIVEN construction to the following-
0 c.epee.in".obk.does peck cu.l DhMlou of Water Resotrces,Underground InjaUen Control Program,
FOR WATER SUPPLY WELIS ONLY: 1636 MOB Snake Center,Raleigh,NC 27699.1636
13a.Yield(Wia) Method of act: 24c For Water satdT E Injection With:
Also submit one copy of this form within 10 days of completion of
I3R Dlobdeellon qpc_. Amwwt: _ well consmrcom to the county heekh dcpsain d of the needy what
constnrcted
Fwm GW1 Nonh Cmlma DepenmM of L+n,an u and Nora(Remsno-Dn am of Wwn Roars Rated Mang 2013