GW1-2021-06287_Well Construction - GW1_20210915

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Well Contractor Name 1 1.t t° 's D iid° 1 r i i�i l
� � fte y fft. P
NC Well Contactor Certification NumberC� r i o' W6 .., I
r3• 15.GUTZ �t 7zf� for ma�LgZE awl ri dk fhR1 (i�all i ca bM
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YADKJN WELL COMPANY,INC. ,> ,,,<z.. FROM � DAAtt�Il� =-
CompanyName " 16. gCA§MIGOR theaa➢mlorrA408 7—
�q �,4 2 t PROM To r9Fp.R iw �
2.Well Casastructio a Permit#o � M�_.
List all applicable well construction permlls(i e.tll ,dowdy,Stale,Val'iff" ,eta) ,, IL in.
3.Well Use(check ever r:se): ft. fit in.
17.8CPCZPI
Wsfes Supply Well: t•e_ N TO DL°.NETEsfl sr.Qasty TERCIUMSS
❑Agricultural 01V4unieipal/Public ft. ft Ile.
❑Geothermal(I'&eating/Cooling Supply) Lesidential Water Supply(single) of g� toe,
❑Industrial/Conmiercial Mesident ial Water Supply(shared) A&GROUT
❑Irrigation Molls>100,000 GPD PElowr I TO NA-11-0 Beal LACEMM4T POMOD ®tnva
Non-Aster Suppy'We86: EL &ae C 7
❑Monitoring ❑ ecovery ft
Frajection Well: & �4
❑Aquifer Recharge ❑Groundwater RemmBiation
19i.uAPLa IGPAIT'L PACK fieti a c a bie
❑Aquifer StorageandRecovery ❑Salinity Barrier Norm TO WATMAL MWEACEMWNEMOD
❑Aquifer Test Mtormwater Drainage EL &
❑Experimental Technology ❑subsidence Control '
❑Geothermal(Closed Loop) ❑Tracer 20.DRUJ-B G LOG aftch mddidam l shee(sif ne-ma o
main Shp.90
❑Geothermal(Ifeatdng/Cooling Return) ❑Other(explain under#21��) Pons >D end e®t®P tlrae4a
$.Date well(s)Completed,
5a.Well Location: Phone ��� ���m���° ry ��� & -A-i�/ e,
�/ A & e
A taw 2� ��� � ✓lea c� pgp 19v
acility/Owns Name Faci (if appli-ble) '
—� Vj
Physical Address,City,0A Zip
County Pared Idontification No.(PIN)
5h.ILffititude and longitude i>a deueesl ra /seconds or dedima@ degrees: ' ° ra Fm � 4
(ifw all field,one latllong is sufoieat) 2z cet deaden.
6°ls(ara)the well(a): germament or ❑Temporar'y Sigcaltne of Coed Well Cont rotor Data
Byslwstthtsfam,I ha-Jy eartef MoB the m i(s)was(were:)aolssh7mled in @c&VMtMcR wtrk
7°ffs this a repair to an erdsting v,9g.' ❑files or foo ISA IVCAC 02C.0100 or ISAHCAC 02C.'0200 Well Cons&wflan Star&w&msd that a copy
Ifthis es a repair,flll out larowaa weUcoastrrrcttote tssformatlorl sad esplalra the r,alt ofdle � �Assbl ewpravtdea#to the tell o:coteP u
repair%odor#21 mmarb section or on the back of thisfom. [
°Site diagmmm or addritional wall dates:
>l.ForeoprobeliIDlPT or Closed-Loop baviug the same You may use the back of this p to provide additional�r�l m i�
construction,only I G'l�1 is needed. Indicate TOTAL I RR of wlis (add'See Over'inRuamdoRtnr).you�alr also t �dif l if Wit.
drilled: .ffiMI `TAF-IMMUC9l1 o1gS p
9.Total well depth below land-surface; �� �12� A)
Submit MO OW-2 within 30 da a of well cow le�®m � 01a fvflaw
�^For mulive wells 141 all depths Rfferex( mple-3@200°ad 2@1009
fl0.Static water level below tog of sung: ( ) � Fog All Welly- G1fgi9ditm,� to D lon of Wye ReSor (D9 R),
Information PrnressimUnit.16171 ' Rblt ig3s,RIC 2Y699-1617 �r
IfwateP level is above casurag,stye'°+"
) Sit;®ff: P�1 B CU` � 20.For ZNection Wells:Copy bD Dt�Unde4pa�d lujwdon Cold gUC)
11.Borehole diameter,
-(id° Program,1636 MSC„Raleigh,KC 27699-I636
11 well coffistrtac4fon method:
,SIR ROTARY 24c.For Water Swayiy Brad DoemL l,'600 Gwilmmm]Reftm wea&;-Coo?to the
(i.e.ange o rotary,cable.direct push,etc.) county aniYoffiontal beam depaariment of fete ca2x AY vvhm in=1�d
P,�R,WA SUPPLY WELLS ONLY LY Md°Yor water Wgus orodadultL 101,0011,Gi D.Copy to Dom.,CCFCU,&
f ➢ Permrt Pro ,16➢1 MSC Ralei i�lt,NC 276 -1611
13a°Yield(gpm) () Lam' Method of testa �/�,
E @/MUTED,
131s.1Dislarfection type: 70%HTH oZ DATE arc Amount.,
r Worth Caroline D eatnent of&vironmental oali' Dividan ofWateal�oorees
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