GW1-2021-06273_Well Construction - GW1_20210915

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Well Contractor Name 0 J DZS
kC'Alell Contractor Certification Number
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(Y,INC. r W ROOKITECUL YADKJN WELL COMPAK IS.GUM CASIN for
FROM TO — =AA I ... -
Company Name 9L
16.1 CASING County, TUMG
2.Well Construction Permit#. WNG &. 053j-106
List all applicable Well construction PeMUS(ae.EUC, Paola To ft WIA73M%L
,
3.Welh Use(check Nell vxe):Water Supply Well: PI
gates
FOAgricultural 0municipalfflublic TO D SLOT S= 4ES5
tural
residential Water Supply(single)
DGeotherrual(Heating/Cooling Supply) ME
0 ok: (tin
rtn aercial OResfifential Water Supply(s d
Industrial/Conin
DIrrigation owells>100,doo GPD
NOR-Water SUPPEY WeDh AMOUNT
13monbring ORecovery
OAqunr Rec h arge ElGroundwater Reinediation . . .....
ClAquifer Storage and Recovery
ElSalinity Barrier MGM TO Rise.
ClAquifer Test OStonnwatcr Drainage
OExpenmental Technology OSubsidence Control
DGeotherinal(Closed Loop) OTTacer, SE a ea ft iGMae nwmmn
013cotherinal(Ireating/CoolingRaturn) 130ther(explain.under#21 Remarks) mom To ON Wk
4.Date well(s)Completed- we Wffi_etf92—:; EL
sa.wen Location: Phone lie— t z
ri.Ile
Physical/Address, ,and Zip &
2L
lqgEL L_U
county parcd maufficatiou 1%.amo ke ing Unit
Mnfinn ProCeSS
5b.Latitude and longitude in degrea/lukutes/secordil or decimal degrees: L)V-v K 0U-U1!V1 I
(if well field,one Wong is snlEcimt)
6.Fs(are)the well(s): nt or E]T emporK7
9-fermane
7.b this 2 repair to an a&fing wen, []vZeg or AO 15A NUAIC 02C.0 fvv 100-15ANCAC 02C.0200 Wen
Ifthis u a repair fill au[loom wellconshuw0y,Dflamagon andoplain the nature 0frAe offhIs record has beenpM wirervidadjo the well
repair w7der$21 refivarla jection or on the barl,ofghisfom.
M diagram or addMond well de .
8.For GeoprobeMPT or Closed-Loop Geothermal Wells haying the same You may use the back of this page to pwvicL,&dftond man
iab
construction,only I OW-1 is neteded. Mcat?TOTAL NUAmER ofVleffs WSW OV6V in R=Mft Bog).You Mr ay also=Whadditione,pops ffnec may.
drilled:
9.Total well depth below land sufface.-
For mWtple wells lid all depths traffema(ez=pje_3@2UU,and 2@100, Submits MG r-TY-n within A daya of*(all cots ggdoa p,,&g
10.Stodc water level below top of,Wring: 49 261- ZOr All We&' 011giEld fD= PiVisida Of Wfitu boa
1f,water level fj above cozft use 1e0r1;20;K=%Z Uidl,1617 h
MSq, Mel9k KC 27699-16
11.Borehole diametee- 401 sit Off.- PA&Por
kkc_*L0_11 Who Copy to DWR,UvdW&M1md Yajection Control(IUC)
FrGffral�1636 MSQ Raleigh,NC 276994636
1.2.WeR comstruction method. AIR ROTARY
(Le-anger,rotary.cable.dh-t push,etc.) oouuPy 2Ac.4g�WSPIP-g2)�mMa en-Loo Copy tou
mmmmentalhowth depaxtMent offhe County wilm instilled
FOR WATER"PLY WELIS ONLy..
2�fil��Fja,jj 11.1 1
7Ad1YorWEcerWdk 1­11d - I I
Law ovw-,100 OCS U- 225'COPY to Dom,,CCPcUA
R
13a.Yield(gpm) Method of test- I PSC, Z,
_j 214 L
136.DiSIVACtion type- 70%HTH
Amount. P, �a Oz DATE SME MINTED:
_1=1L"�U
V989TED BY-
Form GW-1 10-1 M fe 'North Carolina Department ofEnviramneirig Quality-Division of Water pgaoMjWz