GW1-2021-00707_Well Construction - GW1_20210203

WELL CONSTRUCTION RECORD Fa hac col Use ONLY
The hem can he osod kw single or aW1pk wells
1.Well Contractor Informed":
I
Brian Swing room I to DUAI MN
Well Cometown Naas n. h
4240-B n. as.
NC Well Connector Cem6cawn NMaer 1 C
r m TO OLAM['raR TNR'KNaSS MA7Ln1AL
SASDACCO Inc 0 h 12' h 1.5• W NA steel
Contain Nape
rROM TO a44.MRTRR I TNIfYNM I MAnKR
L Well Comrrwelbo Permit a: NI0300399 s 70002483
Lin ell app4rnbf<»ell prnlrir,lie.fwnn.5bor.4'oriarce lr�nisf rn-.1 h h �
3.Well Use retards well me): 17
win"Supply Well: V"m TO .N4M87CR st.OTalre 7N1(TQiDN MATM41
❑Agncubuni ❑Mmicipnl,rpnync 12' h 20- n. 1.5• 4 trA NA steel
❑Oemhennal(Hentm Cooling Supply) ❑Residerrid Water SWplv(single) h h i
❑Ndmtri,UComn"rcial ❑Resideraxl Wdm Suppy(shared) ILGROM
Mot TO MATRRUL I EADI ¢NTharNW A AMOCNT
Olin h h
Nnn-Water Sopplp Well:
h It.
Injection Wen:❑ ❑Retw
h q.
❑Aqutfer Recharge ❑Gnundwdm Remediation
❑Aquifer Staagc and Recmen ❑salmitY Banter 11014 M R TLa. M
IL TO Is.
❑Agla4r Tea ❑Stormwelcr Dimaw n. h
❑E,perinRNRal Ti chnolM ❑Sebndcmce Comml
❑GeabemMl(Closed Loop) ❑Tracer rroar to ao4,armx Olbr .a'Iwe a.
OCseolhemW IHemi odi Retum) ®Odin(vipham under B21 Remmbs) 0 h 20' h
h h
4.Date W'en(s)Csmpkled: 1/12/21 W'di H18A22
n. h
5a.Well Lmatinn: h h
Remadiation Managament service Company h n.
FaaWUwaei Nome Ficilrry IDr(ifapplicabkl n h --
26SO Shenandoah Ave., Charlotte, NC, 20205 q q
Ms"Addnss Of)-Wad Zp L
Mecklenburg - 12710204 Temporary injection point through DPT tooling
('00" Paled ldcaneama No (Pm)
*14OMde and Longkode in delfepinhsm shcom its ne dedmd degr[ec 22.Cerdflemdes:
of well aetl,code Iabluag a sutflcebl
35.210533 N -80.801887 Brian Ewing 1/27/2021
[U SW MeofcmLfwdw'dl Cooacbr Doe
6.Is tarsi el
se wdllsl: ❑Petwaeem ®e or Terrponry B,,.r,l.lr rM.A.nw.I Aereec.ru/r rim the.e/Axl»,,,r»rnl.r+r+rarr.d w n.oNmu<
a11A!sA NCAC 07C.010)nr 1 SA NCAC MC 0a0 WeB C'nws m con 6roxdrrrdx md+lnnl
7.Is Ws a repair to ma adding wen: 7Yes or ICNo r,ps rNrAl.rry o.d Aa,Arrx pn.rdrd m nw»r!1 n.nr<
IJOu rs o rrpoie fill ae tnrnw.rU,rwrn.'A,m rnJoriwrnn,od ryd✓rn rAr nrr✓r<a/rb
rrpvir.Mrr n_I rcwart.,rrw,o.nw fir Ault pf del,N+ra 23.Sbe dhlpem or MdlYod well delans:
Yon ma) use the back of do page to li m'rde additional*yell sat details m well
S.Number of well tondroeted: 1 conunsction detail. You am also Brach additional pages if necessan.
For wdaplr w,*rAln to nrol-.env upph wells OA'LV tiah dw mat,emmwom ww.,m
,adw:+�rwh ww. SURMITTAL INSTUCTIONS
f.ToW"dl dCMh bd sw lend snrfue: 20 (R-) 24a. Far An Well: Submr this fan wahm 30 days of completion of well
FAr.W,O,.ellr 1fp?W,,M 2#Inrl caWnrcnontothefollowing
-
le.Stodc wdar Ind bib%tap al c.shaill; OL) Disidan of weer Raorrtes,Wermadeso Processing Unit,
y.awr A•rrl u dmm..uan.w-. 1617 Man Smite Ccwtcr,Raleidr,NC 2 769 9-1417
11.Borebk diameter:I.5' 00 24b.For IRkmiOo Well ONLY: In addition to sending ties fan to the addicts in
24a abme. also srbnns a copy of this Imm "shin 30 days of crostipletion of well
12.Wen tommoetlon EWtbod:DRIVEN Imninsction to the 10110wiog.
41 e.MW.'me).cabit direct pink do I
Dh'lNR of Water Rmaosees,Usderyouod IRJecdom Camnl PmV=.
FOR WATER SUPPLY WELLS ONLY: 1626 Man Service Center,RaIdgh,NC 276".1676
I3a.YkW on) Method of win: 24c.For Wdm Sopith f lolectieo Wtll:
Also submit one copy of this fom within 10 days of completion of
f3b.BWnferdon RFe _— — _ Assistant well commrction to the comny health dcpmmua of the casm'wbm
cosamncied.
Fora(-W-1 NonhCmWw DCpounom d Enintim m and Namd Resooccs-Deis... m,Resmem Ran eed Aspot Mil)