GW1-2021-00667_Well Construction - GW1_20210203

WELL CONSTRUCTION RECORD For leenel Use ONLY
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1.Well Contractor Infermatem:
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Brian firing tROM To pR(7r►ttDN
Wen Cowlraum Name a a
4240-B h' It.
NC Well Co(tmdor Ceniaco on Nmober
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SASDACCO Inc 0 a 12' a 1.5- 4 NA Steel
Comport Name '
FROM 70 INANUTIN TmiCiPnM MATTRLLL
L Well Construction Permh d: W103003991 70002483 h. It. {a
Lin all apPrir'atlr ar8 purses fu.Cawvy.SIm.Veriair�.h�Krbf oc.l a It. 4
2.Well Uk(ebeek well s r):
War Smpply Weal: /ROM I10 pNMtlaa M.OT 1Blewm®s MATrWL
❑Agticubural ❑M0B1CVILTWic 13' a 20' a 1.5e la NA NA Steel
❑Geahn es lHeatiogCoo6ng Supph) ORewdemkl Wamr Sappy(drple) a a is.
❑hdlmtiiaVCommercial ❑Residential Wfrmr Swlp (shrredl OL
FROM To MAT[mAL I [MIA[TIB.'nT M[IBW&AMOCTf
❑irn ti. It.
Ne••Wafer SMpply Well:
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❑ OReATn
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❑Aqu*rRecharge OGmmdwala Remediation
❑Aquifer Storage and Recmvrn OSalmgv Barrier
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❑Agoifrr Test Oslo..— vi-Drainage R. a
❑E)Vent cnkl Twhaologv ❑Sobrideoce Como)
OGeothennal ICesd Laopl OTsces FROM To troe�ro.aM, wnveet tile.
OGmthemd 411estrigCooling Retinal 110dw(vililars under all Remadot) 0 a 20' a
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4.Dote W'el(s)Cempleld: 1/14/21 WdO IDdA2
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So.Well location: It. a
Ramediation Management Service Company n. a
f:ilMrOwoo Near Fwiho We(ifrpp8ublo a a
2650 Shenandoah hve., Charlotte, NC, 28205 a a
1'hlsrcal Adler¢City.red Zip
Mecklenburg 12710204 Temporary lei action point through DFT tooling
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5b.Latitude and Lemott de in depeeslmerOnhmwds or deeimal degrses: .
(it-CH eetl,me 1a67o1w a at8ckal 22.Certification:
35.210533 N -80.801887 W Brian Ewing 1/27/2021
SWoarm ofCenakd Well Corsrew pas
f.Is(are)Me wells): OhTmament or mTti sporay Ih,i der k—.I barb,rr
a'tad ,N''abm Nr xrWs1 wv Iwrnl.,xwnw--IrA w aarolJarr
eirh I5A NCAC 02C OIM o,I M NCAC 02C O.W Wrd Gwaneeana Srwrdardi and.An a
7.Is this a repair to an eaiMfft well: OYes or KNo .,I}Mftk,Hca,d has berm p,a.kd m Ab x.N owwvr.
If wls,r a Hpai,,fib cw1l,ana wWI,ewe xnrm arformnmm,eW explaas�.rhr.wc.,4,l7Ar 2 O
rrpvir ands Rr HmaAr mnae air an rf a oort f due farm. -.--) .SitertiaRram or aditlerd well demtla:
You no) me the back of this page to provide additional well site details or well
S.Nombes of wells constructed: 1 wmtimotioo Iil'mels. You mar also mach addinond paged meceaija For aw&pk IajH rAw,v row-rarer s'IrPA rA,ONLY wrh IRO game mosweea m....
salrmirar Cols. C IBMITTAL INST CTIONC
f.Teesi well depth below IaM mRacc 20 (D.) 24a. For An Wdls: Soh au this form wi1Hn 30 dns of coroplam of well
Farm*Wk welk Ii.. deFrh,if drg}Hnr rrrmwl+fr-?Ip2(IF'a.d?@ I I cesmnation to the folowiog'
la.Static water kvd beta imp of casep (fL) D(Ween of Water Resources,Imformmam Proceed"Usk.
fJxaw,krrr a a4aH,armr ew . 1617 blal Service Cater.Raleigh.NC 276WI617
I I.Berebde diameter:I•S r (e.l 24b.For Imiedipm Wells ONLY: In addition m seadimg the form to the addrem in
24a ideat. aho MbmY a copy of this form withe 30 dmT of completion of well
IL Well eosMrmclea metbN: DRIVEN oca tnscdow to ibe following.
Oc.a tcr.mbmy,cjbk,dime path.ae.l
Dh'ben of wake Resources.Underg oved I*cd m Control Pmpam,
FOB WATER SUPPLY WELLS ONLY: 16M Mal Smite Center.Rak&16 NC 276f-16.M
12a YkM(lpm) Metbd of trio: 24e.For Wake Sopdv A,iolvidea Wdb:
Alto subset one copy of this form within 30 day'sofwmpletion of
13L Dhimfecdon well comaon to the COUM Icab � Me h of cousmy where
VP�. ARmmmt: cursmcmkd. b
Form GW'-I Noah Combine Depanrawm of Em nousev,mad Neural limo es-Dnwme of Weser RmMm Record AtVJA 3011