GW1-2021-02625_Well Construction - GW1_20210809

WellConhactorN e - +Tell _ TO: LsSCruT+ott
57�P to
` ` �
NCWe11ContractorCeslifieetioaNember OTPPEIICA�TG forenulti-diedt® URLUQM ifs lita6k
YADK N WELL COMPANY,INC. PROBE TO Dr�A°T�'= TffiCrtNEa9 TttKrt+L
Company Name
16.51tIlRR CASING OR'!sU1SING ., ti �g1elaseddob'
2.Well Construction Permit#: PROM. 7o DrYt 1ffi(atPopss agx .
List all applicable well constradlon permits(ce iJIC County,Slate,Parta=4 eta) l ®in. :-
3.Well Use(cheat ttrell r•,se):
Water Supply Well: 17 SC 1L MM
zFON, To' nlJUAE a Sloasre - T5TC:(ra>;sc MATERIAL
❑Agricultural ❑MunicipaUPublic,
❑Geothermal(Heating/Cooling SuP�rde antiaI Water S I FPI y) *S upp 1('single),
_
❑lndustrial/Commercial OResidential Water Sup plys(shared)
i, Ga',Caele
❑Irrigation OWells>100,000 GPD. rrrom To: tyA;�trr.+,� >rNTLACOWT MTHOla c�ATIOU tTR
Non-Water Supply Well:
❑Monitoring ORecovery R tl: Pei /mod &
Injection Well: Y
❑Aquifer Recharge OGroundwater Remediation <
19-9ANDIGl�A��ELP�iC1�Ba '"`°b16
❑Aquifer Storage and Recovery ❑Salinity Baaier '` FROM. TO alATERUL •t+�rAC'�[:4E[V'&remora
❑Aquifer Test OStomiwaier Drainage
❑Experimental Technology 'bSubsidence Control ft:
❑Geothermal(Closed Loop)
❑Tracer 20.DRl�Y.1�7G LOG'attacL addtd6®al sliee�iimere�sa' f
❑Oeothemial.(gexffi&CoWiag Return) '; ;❑0thei(*lain under tl21 RemarIxs oaf 70": n1 oN color soatme>k ' °
f'
- Q
0
4.Date Well(s)Completed: d Wen JIM ® : .®
5a.Well Location Phone � . 0V — ��
Facility/Owner Name ' FaciltylD#(if lieabl®)'
+
Physical Aaa � exr,aid zip ; `
11.,RMWAMM
�
County PazcelIdemrfiuiattonNa.(PIId) _ �e
5b.Latitude and longitude in degrees/miaufes/seconds or decimial degrees:
(if wall field,one 1806ng is safficieid}' 22.Cea lt5catio :
_ o
6.Is are the s: ermanent or -OTem o Si °f ConCractaii` Dry
Is(are) O p. y ,
stgnbugthisform,l hereby certify that?he well p)wn s(werel imuft eted in accar'dencewilh
7.Is this a repair to an existing well: Dyes or o 15ANCAC OTC.Od 00 or ISA NCdC 01C.0200»elr eons6aeelroti Slan�mdr a rani a espy
Outs record has bear'mvidedi0 the well aw0er.
If this is a repair frll outlatown weU constructton it farmatiorr d espJaltt Phe n0ivle ofthe 01 P
repair under#11 r mw*raedtan or on the bad ofthisform.
23.Site diagram i.or additional well details:
!l.For GeoprobeJIDT�I or Closed Geothermal having the same You may use the back of this.page to provide additional well_coa47uction Ab
construction,only 1� l is needed. Indicate TOTAL NUMBER of wells (add See Over in Box):Yon may also attach additional pages if necessary.
drilled: 24.SURNHTTAL I1�1S'[TRUCT116 iS
9.Total well depth below land surface: " .50
Submit this GW-1 within 30 days of tom letioa er the foil
For muttipie wells Art all depths ffu$�e-d(=mnple-3@200'and a(a)100) Ya p p owing
e .
10.Static water level below top of casing: 4� ( ) for_Alt bells: Origmai $orffi to Dieisran of a e Resotuoes-CDWR
If water laud is above cas6rg,use Information Processing I61Z 1�d Raleigh;MC 27699-1617
lI.Borehole diameter: ��(�,) Bit 0fl6 s � ' 24b...For Infection Wells:Copy.toMM.Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 2v699-1636
AIR ROTARY '
a Well construction method: 24c,For Water Sat a and Open-Loos Geothermal Itetnru.Wells:Copy to 4lie
(ie,sage,rotary,cable,direct push,etc.) county emruomnental health dep_"ent of the county where installed'
FOR WATER SUPPLY WELLS ONLY-
Md.For Water Wells vroducing over 100 000 GPII:Copy to DWR,CCPCUA
rrpp Permrt Program,1611 MSC,Raley ,-NE;27 99-1611
13a.Yield(gpm) e� Method of test ��� t. g
t
70%HTH OZ DATE SITE!/ISITED:
13b.Disinfection type: Amount:
VISITED BY: