GW1-2021-03036_Well Construction - GW1_20210622

WELL CONSTRUCTION RECORD F�t�tl�t use tirn:v:
'Ibis farmcun be used r silkas tnnlG mns
1.Well Countctor inforroatiocr.
34,,•TA. ZO1V
Robert Miller "OM I TO I 0 P1F10"S
t 41 Coutta'dor Nam , A.
2675-A fG fL
NC Well Cotar.+ctorCe1ifre*16nNut*er #i i�fSfrIfF a►Pirai Frisxttd�reps bat :fill t7eab ,'
FROM I TO DIA'JiB'M T111Ct%TM MATER1Ai.
SAEDACCO Inc 0 fL 5 tL 1" lie. SCH-40 PVC
couvw►am T6.1 NG: ,R: IPtC tiaim� ln�d=i'
FROM i rO 01A.#ETrAt TinCKAi S MAi1FWAL
a.Wait Onstruction Permit� it, t1: bL
Umafflwiralxle wrlfprmritj(lan.COVAM Smv,Variamre.Pta-d ;t em)
3.W011 Uric(check well us* a.
Water Supply Well: FROM To arA4t1RTPOt ; c,or )a I T1nCt1M I MAI"IAt;
Ofti ultuml 0MnnicipeVPubli,c 5 (L 10 ft 1" 11L olo' SCH-40 PVC
0GooIk nnal(HcatingtGooling Supply) Olkesidential Water Supply(0081e)
01ndusBialX61111001dal tlResidential WatefSapylZ(shawl)
PROM TO D1Ar IAt. BAtFLACi.MF\T 9MOD RAtH U-0
OIr�t lion. tt. fL
77
10 1
NaDAWatcrSupPl!Welt:
i>DttJltanitgrin Ctit¢Cat '
CaAgttifetltecharge QGroundm€tcritetttedititicm t9u. Ti ►, ;
trtfer$t alnclRce4t C1Sgiin 81€I[iCgr Mold, AlArvaTAl` A LT n
3 h: 10 ft. FILTER' SAND 1#2
QAgitifer Test fiStOrmn'atcr t7r�cip9agt
h: h;
OF-verimcnial Teclumlou 0SASidcnet Corot
�0.=1?Ri1�IJtAi�� JGi's11st#i�dr��edsi�s s .:
❑(itodle ual(Closied Leop) CiTrAm FROM Tt1 01SCR1FiYO`rear bsNn t a�mex .
[7Geattoemyat Oleatjl&Cnoli' ReWffl) L70aer texplawunder 02l:i2ctna& ft. h.
h R.
3.DatcWet)(s)Conmpleted: 6/1/21 Wdtn)#SB-6 {t„ If: r� l
So.Well Location: ft. ft.
Blevins Oil ft, t1: I`
FwilhyA)ivmrNw= Fsici7il)-IDil(ifMpfiaabic) ft. ft.
i-FARe:GR rr+ ne a.-i Unit
6014 US-19E, Spurce Pine, NC, 28777 h a •
Plosi al Addwm C- ).and Z p 2f.Rii'ii.
QVY �.S laO€1
Mitchell Temporary well
Casumy Direct tdcrrtirreauoa 14b,{P1N)
Sh.i ntitudcand i on>itude in dc9Mca!'mi0utcstste6ndsordecinntl degrees: 22.CerWwatinu
(if z*t(t field;ogre illflQtglt m4fK6d) -m.., '
�< W � 6/8/2021
S€Fmtnsoof .'cal.�tt wrt' �^-= Dale
d.is(art)the wrll(s): t2r!tsuYnetrt or S11'emporety B sigN4,V&ht0n t tknabj•a*-*'thAV a4-u441)Wont iWe")4,cMM"eted in 0K+e4ad"ree
with 15A MCA CQC'.01 M or ISA vCAC 02C.92W Wttf Comimaian St4nA rds to d titan a
7.Is this a repair to an eil,,0mg well oyes or MNo ropy e drls nw•tnvd h"brrn prm w to Ow"rafmwr
If ft it o fqw1r.fli mr R uwvi uvU a wutnotan iifonnorton m d r,;pftaht Or imrmfrr e-f d,
repair arWer021 remarin Areawn or tm do bar1;of dhds forAL 21 Site dinram or additional vk*41-dtxalls,
You nth•use fire baek of this pad:to pm% additional well site details or%tell
8.Number of wells corAracted: 1 constiuction detains. You m3V also attach additional pages if necessatn°:
Fvrtrxt1a11r1r 1a�errinra:s+r Owl-water ssrnpdr W115 ONLY afthA&WMtt+onstrneom.vary ran
9.Total ndt depth below land surface: 10 (ft-) 24a. Phr All Will Submit this fann within 30 dsys of completion of acli
For;titrrlti)rirWU*fin olttl"rXuh(fdo"Jl'errn1kxffl 1r•30200,and MOT) eon5tnlctiuntothcsfoihrning;
10.Static water IMA below top of C"ino 00 bivision of Water Restuirt a.information Prot inn Unit,
tf mart k vN U abme rrtartnf,um"+" 1617 Mail Service Cmtcr,RalcW,PVC 276"4617
h
11.RorehoM diameter 2.2 5" 24b.Egr intent on 1Vs7ls,ONLY: in addition to sending ttte form to the-address in
24a;emv- also submit a copy of this form within 30 ft-s of completion of AM]
22.Well eaostrnetlon method:DRIVEN Con"ction to the(blJowing:
(Le.Moser.rams;.cahtc d€ *A cto:) Division of)Pater Restoarces,i IIndetgrrtrDa Injection Control P1Dgnttn,
FOR WATER SUPPLY YELLS ONLY: 1636 Mai(Sm ice Center.Rt ldoil NC 236"4636
t
134.Yidd(gym) 1►3cthad of tests For Water Suppl)&la�octRru�14`dts:
Also submit one cW of this font vOthin sap days of completion of
Avell constmction to the count) hcsiltti dcpadman of`the coon what
13b.-Dislufett(on h1v:,_ Amount cvn meted,
FarmGNNF-t iiarihCmalimftatr=leflmi'muravdvdNamralResomms-:t hisbnofXNafi>xRdattM RctiiscdAteug2013
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