GW1-2021-00403_Well Construction - GW1_20210129

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WELL CONSTRUCTION RECORD(GW-1) For Intcmal Use Only,.
1,Well Contractor Information:
Ronald G. Cannady 14.\VATERZONES
rmON TO "Wa mtco;
Weil Contractor Name to R U R.
944
2126-A R. R
NC%Vcll Contractor Certifrcnion Number 15.OUTER G151NG far malaamd wel4 ORLINFJt a • Itabk
Cannady Brothers Well Drilling, Inc. TO DLL\IE�rt TMI�NEss "ATE"'^`
R D n. r. IR "is X&
C.infany Name �{ 16.INNER CASING OR TUBING rat al desed-Ift
2.Well Construction Permit#•A d •• FROai TO DIA4IETFR TRICIu\6c )aTERdL
fur all appliro6le mall rnnrmation pemaias fi.e.I11C.Comm•.Smar.I n mar.el.) fL fit. la.
fu
J.11'dl Use(cheek well Ilse): ' FL fL
Witter Supply Well: 17.SCREHN
PPY � rROw TO DU SLOT TE TIIrCKNFSe AtATER1A1.
Agricultural �MunicipaVPublic O R. R I ra. O/f fd. y/g4ruM
Gcothcnnal(Heating/Cooling Supply) J;Kmidential Water Supply(single) R. R In.
IndustrialiCommercial QResidential Water Supply(shared) IL GROUT
Irh 'lion I/h / ftinto1 MGM TO MATERIALEll PIACENIENTPt:171tOD&AMOUN7
Non-Water Supply Well: - d 1- R &*misfit P
Moniloring R—,,-y rt. rt. 10aaaat d G 7t re 3e y
Injection Will: R• p• /
Aquifer Recharge ©Groundwater Rcmediation 19.SANDfCRAVEL PACK d bk
Aquifer Storage and Recovery DSalinity Barrie Mat I To I MATERIAL E\IPLAC'ET\FAT1 wort
Aquifer Test DStormw'ater Drainage '�V R- d R• I y o / 1441,4
QMYI
Experimental Technology [3Subsidc cc Control (L IL R.
Gcothemml(Closed loop) [3Tmecr 20.DRIIJJNG LOG attaich addlWnal sberar if
lRQN TO DESCRIIf10N aokebm,lam.aawnek 4u.ere
Gcolhcrmal(licnin Coolin Rctum) nothar(explain under#21 Rcmad-s) R D R
0,,,0 /• /Y-31
4.Date Well(s)Completed: Well ID# °• O R C
5a.Well Location-. / /q•1 1 O IL o R
R R MN+
FaciliryiO+rmn caw Fuifity 1Da pfappliobk) p°' 7 0 It. F S�na.raQ
!o 151 T w�4t11.Q RI F/ .rJ�i N 6 o h Cwo^"
Ifiysial AJdrtsc Ci0•,and zip/1 Q Y E VL.
l•a C y fZ- 3i- DJC 21.RERIARKS
County Panel Identification No.(PIN)
5b.Latimdc and longitude is degrcWthinatesisesaads or decimal degrees:
(ir,+rell/field.neehafkaigoRl wcim) �l 22.Cnertific_attiionn:
3 6 . / (�7��7/N -7 6 ' -72 %91 3, W L—enORK /-
Signature,ofcerified\VellCommesor Date
G.Islam)the well(s) AVII
PFrmanent or Ql'emporery
Rr signing able JomL I h,rrbp mtfj'than the nr0(+l has p+rrel mmtnraeA in orcorrlanrc
7.Is this n repair[o aR esistiRg weB: QYa or �PIIt' aiah)Sd NCAC 02C.0100 or 15d ACdC R>C.0200 II AI Construction Samdart6 umf that a
Ifthis u a rclmir,fill out keroua url1 rnnnnrnlan it formation and explain the wear,of16e _ copy ofr6is record ban MrnPb+�d m rM ud/name.
repair tuaMr 021 terraria section or an the beet*uftNir_imni 23.Site diagram or additional well details:
P P � ¢ ^Vgu may use the back of this page to provide additional well site details or well
S.For Gco robelDPT or Closed-Lao Ccotbernml Wells having; to"* "ttonsauctjon details. You tiny also atach additional pages if arccossary.
construction,only l OW-1 is hooded Indicate TOTAL NUMBERu, rills
drilled: e ,l SUBMITTAL INSTRUC770NS
9.Total well depth below land surface: P y (R) 24a. For All We16: Summit this forth within 30 days of completion of well
Farmultiplcuelh lira all dvyarke ifd6Fe 10 famnnple-3@200-and 21i lmr) construction to the following:
10.Stadc water level below top of rasing: (ft.) Division of\Veer Resources,information Processing Unit,
Ifuae,r Invl&"Iota casing,ae,4' 1617 Mail Service Center,Retleigh,NC 27699-1617
11.Borehole diameter. s (ill.) 24b.For Iniccliun Wells: In addition to sending the form to the address in 24a
o abort,also submit ant copy of this to=within 30 days of eomPictim or well
12.Weil rnnstrnction method: n� 'r 7y construction to the follavinir
(Le.anise.mury.able.direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield Won) -1 Mctbml of test: _ 24c-For Water Sum ah,&Injection Wells: In addition to sending the form to
1 o the addras(o) above, also submit ana: copy of this form within 30 days of
IJb.Disinfection hpe: NT I� Amoaot• F� r y completion of well construction to the county health department of the county
where comtrucred.
Four Glv-I Noah Carolina Department ofEn,•itoranenW Quality-Di,ision ofWatm ltcs s Revised 2-22-2016