GW1-2021-03038_Well Construction - GW1_20210622

WELL CONSTRUCI'I:ON RECORD 1'�tttsrnaivuoNly;
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1.Welt Contractor Information: !
14. 'A3tttit
Robert Miller rR Tar T D ttlt'r '1
Welt:cortm aw Raratc -
tt, (r.
2675-A
NcwtjfContracaorCenifrcatlonNttn6er FROM
I To111f3 ar,bai-VIA?iced tl t?TPUCK:R. .tt'tfcablt
ARn�t To nTA�teTsft_ sttrcatINTM arsI"tAv
SAEDACCO Inc 0 (L 4 ft. 1° in. SCE-40 PVC
faacaltotc at o t 16.1 3 O YIRi81TTG' - at. xau
6ROt1t TO I DNtlSBTER I Try I MATERIAL
2.Wd!Constr uxtino Permit# R. h, hL
Lim et)epplirvhlr weN/trrmftx(i-v.Cmmly.$ ,Variamr;7tlrecUtn rlr.)
ft. fL fo.
3.VV41 Use(check well s so, f 7
ilaPRO." TO DIAL%19MR T T W, 7t4tt�#.� MATF�R1AT.
Water Supply-Well,
DAgticultUal clmittiidpatfftlic 4 ft. 9 fl. 1" IrL old SCE-40 PVC
DGeolheaunt(tleatinstooling StrMly) DResiden iat water 5t"l (sin&) n � 1L
131ndustriallCornmercial OResidenfial orator 5trppt*(st md) 3R:a;ROlfi
FROM TO MATTIREAI. NYMACTMT•cNT)WMOD&AMOUNT
D'Irfi` tion (L fL
tlan=li"arcr,Suppt Well: ft.
t>aMaTritorin ORect» '
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pAgaiferReehargt QG`ratttidtra+ferRentediation 'FROM aeArttaTai: PnrPt tivTM, r n
0Agvillm Storage and Rocavrr GS.9linilylbrricr 2 0. 9 ft. FILTER SAND #2
1]Atltr1fcrTe9 tOStorinwa rIhtiinap
DExtudmcnW Tmhnolog 140sidence Cor tnl
s Rtt�'G' (�"aYtsel,�ditHtnnatitt,eei�tF._.
MeothennW(Closed LOOP) f]Tratxr PROM TOo rtmTtts awe gsrae eai rea q
DGeothential ffieafitxKt2 Rmrn) 130dw( lain under#2 t.Rernaft
4.Date WOW Compieted: 6/1/21 13rd11D9 SS-3
fL (L
Sat,Well Location: (L
Blevins Oil (L ft. N 4
F,ncO y rtcr tamr Fulft WO(ifopplicsblc)
mrtg lYtvt
6014 US-19E, Spurce Pine, NC, 28777 fL (L DWR Section
Plos;ml A.dd=L City.ar dZip 31,9 "
Mitchell Temporary well
Calmy Pamet idt rdii cation No.(Pfi�)
5h.Lathode ttnd.ie ngftuudc in dcgrecs/minuteslseconds or decimal riegrecF. 22.Certirreatinn:
(ittstff field;One tatllotig iS 8adtttC*td)
W 6/8/2021
1
6.is(ate)the well(s): t3ftrntanent or oTemporatT > & +p drtr fail I hxirbj aNrl fn reardiu,s rlys p a6�Cr a+vrrrf olwinwred in&V044nre
whA 15A NCAC 02C.01M or IJANCAC q2C.QXXi 1Pe11CPmtmrtlan StaTradards and rlarto
7.Is this;a repair to an rcrl'5ft well: 0Yo pr MNfr r,�r�f rhFt►Msr.dMas beew p+►mkk d ra tte a»rlt r�xrr.
1f dr1S tr o fepakflY out known w dl cown"ton h1f€,mmikia and exp(aht-the mr are prof the
rrrm#rrutrlrri631 rernr+,iFx snctiara or ara thr tr,aci atf slaty faun 23,Sltedlm or:lrl$i110na1 Nell detalL4:
Yost may use the latek of Ws page in proNide additional nvdi site details or well
S.Number of velis contracted: 1 contraction details. You atm also anneb addidatutt pages if t ssan:
For mldtffikInje()nrier ONLY vifth dir wmeovirsumAmr.you im
=bft~farm. SUBMUTALINSTUCTUM
9.Total well depth belon land surface: 9 {R.) 1 tins!hurt ntititin 30 dm's of cougttdion of well
Fur.arml#ipl I Ut hSr4M*PAS i1d rrnx lercMJr10-J@24W'#Add@AW) conwictionito f f ltovring, ;
10.Statit:Water IM-61 belOW top of rasing" (tR.) Di8 isloa of Water Resoetrem Information Plocesalnl Unit,
1f matter 44,011 it dbdkV t,4At,use^+" 16171lfSff Service Cepter.lalcig6,NC 276994617
11.Borehole diameter:2.25° (tb,) 2417.E+rir inWWa 3W13 ONLY. 1n addition to sending the form to ftaaddnw in
24a abme� also sOn it a capv of tads lem within 30 days of completion of wil
I?,Well constnKtioa atethod:DRIVEN construction to the following:
tie:au .►arse.celttG dbw ash coc) Divii1on of WaterRmurces.E �t►fgttoud InJreltttn Control Izntpxaln,
FOR WATER SUPPLY tNTAI S ONLY' 1636 Mgll Service Ceiitttr.Ralrfgh.NC 27699-1636
13 l e4d fgpm) 114ctfrod of test± Ur-For Water SvWJX axe tocxtton!Nadu
Also submit one colt}•of this fortt't AtAhin 10 days of cotggetion of
13b.Disinfection tvl AlmcnM well construction to the calmly heilth dc�trtnt�tf of(tic coumr tt�hm
constnicted.
FacmCaitt-f Nunh Carolina Dqun ew of£mimnmimt wA NlaturW Resoumes-Dii iiionoMrster R60trm Rewired AWA 2011
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