GW1-2021-03039_Well Construction - GW1_20210622

WELL CQNS�UCTION RECORD 'For ifertmlUseon'y:
Mds-form can be aced to An*of multift UOs'
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1.Weil catuin for Information:
Robert Miller FROM D "'noV
A'a t<ortttmvr t tani� ft fl. {
2675-A
NCCVsll CnmractorCenifa�li>snNFiurDea
:f.0 '� ar:au'Mlyoaed� t31tNYf2€#�` t1caG'
FROM io 11 nra,+sFssR TF", 'S mATrm.t.
SAEDACCO Inc 0 h., 4 tt 1° ie. SC7-40 PVC
Coraptury Pi�iae �43 ;. oR'#�tiiNlt:' '. .� ,.. .. ..
TROAt TO I DWWTGR ITtln'1+TESS MAIV..UAL
2.Well Construction Permit*. b. {h 1 `,
1..11f411."fimmtwttp-do fi c.County,sw2 vdrinnre.Dlilivacn c t) iR.
3.Wdl llse-fetioelc Well uic).
WwterSttpltly'Welt: -FROM To nt nt rr.R AtrS1 trttctcAPSS MAn'.'RiAi;
DAgticatlhl'Ril GtMnnicipallPtibiic 4 tr. 1 14 (. 1° (m ` .010 SCS-40 PVC
C)Crcotheand(Heati ooling Supply) DResidential Water Swh•(single) fl. �; K
industrial/Gottimetcial S l R.estdctltbil Vitttter t tI 17ROU
Supply( toted) FRoM TO MA-TWW, n-MAC 2 Ma�rnan&AMOtiW
❑hr lion h. f1.
NOR--Water Sopp$Well
MMonitori t]Recoc
injection wdl: tt. it.
0Pgnif9rRcg1hv a OtimundunterRcuiediation
M ifcr St c and lteco1 OSam lin• 'Harrier RatPr
FR :w 3FiaTRatA7, .A rNT , n
Otte } 2 tr. 14 ft, FILTER':SAND #2
❑AgoifcrTW 0StOrnnNVcr Draiml;;
fti tt:
13EVvimcutol T=bnvtogy sidmce Conhvl
3dr.�IOTtILiAIeCTesta-tglisic�" Ililniry:�l�1stf"'
Mveotl mial(Closed:Laop) aTrncer sROM I m PFSCRM'f0X oA bawn 111rxrc .Ott:
o(3eoti►erntal ti r oli Returi) t70ther under#1 ltemiks)
tt. ft.
4,0ateWell(OComplettd: 6/1/21 WdiIDASB-2 (f.
Sm.We"l.Aeatitm.
Blevins Oil
Fr II .K3ivtrst Name Facility 1Dit(if vppti=ble) ti, tr
I ry
6014 US-19E, Spurce Pine, NC, 28777
PktiwlAdAmss Cim.and,Zip 3t ft ttt
Mitchell Temporary well ��d�J SQCTl�f1
Cattily• Panel WAtIr;allon No.#4 t)
Sh.L titadc and i cingitstdc in degrealmiinntcstseconds or decimal<trgtecs: 22.(lertif'a atinri.
(it well(t td,one 120mr,b soltittd)
W 6/8/2021
SiiatH�A,�' t !t� r�" �. Dec
6.is(are)&e wdl(s): t7Permantat or ZiTemporary ifr Ak rlrir J6no,1 herder).tvrigy thw the vwMA1 uvv(werv)cwvWwaid is aL+tord4tmce
with I SSA rYCA(7tl2C.01M or l L4 MCA 02C.029AWell CAnstiur flon,5MMdrds and W a
7.Is thbi;R repair to an ezittin well, t31'� or ENO) copy of(Ahr rr onfiwsbe ,,pmrirkd to n4r n,li awnrc
lfAiskt orepok ftlt mt known uvUramtruertoo ktJorawfian and erptain the Mrure el the
repair a der#21 rmartt snararr or an the barl of this foray. 23.Site diagram or additional n•ell.detalb:
You:may Use The Back of INS page,to pm%ide additional tr ll site:details or wdl
&Number of utlls constructed: 1 cousimcdoK details. You mmy also 8 tach additional pages if necessafy.
FOP ntnh0,pie lgkC laor or WAU ONLY n•lth dtr sarnteonsfrartfon voa can
9.Total wdt depth below landsdrfaw 14 (ti,) 24a. For Atl Wells: strhmit this form witinin 30 day's of completion of Ott[
ForAwmpk ions um all*Frhr tfdifetent{ermVla,-31w2m,am @10p) constriction to iltc Potion ng;
10 Static hater lmvi below top of casing: {ty) DIVIslon of Water Resou acts,Information Processing Unit,
Ifuv s,level lly sbaer edAM*use"+" 1617 Mail Serrim C�aUw.Rmteiah,NC 276"4617
1l.Borehole diameter 2.25° f ) 24b.Ur Ja itil WQ ONLY. In addition to sending the form to the.addmss in
24a above. also Submit a copy of this formm within 10 days of completion of hell
12.Well eonstrtieton inethod:DRIVEN cmituction to tk 110110%viag: � {
te&vWr.rabry ab,c.died vask eoc.)
tlh,lslon of Water-Resources.Underground Infection Control Program,
FOR:WATE R SUPPLY WELLS ONLY. 1636 Mail Semite Gently.Raleigh,NC 276"4636
13a.11do(Rpm) mcitiod oftew 24c t•or Water S17W iRiceth}n'Wetls:
Also submit one oW of this forri Mthin 30 days of completion of
13A.-Gidnf on Amount 'well constriction to the cQ=ty llc hh deparinmOt of the county where
wnstmcted.
Farm OW-1 N"It Carotins Dq mftmdsf F-mim=DzM mA Minna-Rmarm--Mkionof'llrala RftgxMticils�d altagtk# ti
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