GW1-2021-00840_Well Construction - GW1_20210322

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WELL CONSTRUCTION nRD(GW-1) For Internal Use Only:
wWell Contractor Information:
Ronald G. Cannady IL WATER' NES
snDal TD DESCRIPTION
\Yell Contmctw Namc R n.
G
2126-A n. n.
NC\\'cll Conlmclnr CartirKadon Number IS.OUTER CASING for®d6ased webs Wr. b*Cannady Brothers Well Drilling, Inc. fROM n, TO m DIAMETKERmS-3 CompanyName 16IINNER CASING OR TUBI bereFROhI TO DIAh1ETER
2.Well Construction Permit M: V U
Lvt ull nppliraMe urll rrmslnmion pennas lit.IIIC.Crmn".Sm(t.l'e mce.cm.)
R n. is
3.Well Use(check well use):
11.SCREEN
Witter Supply Well: r•ROAr TO DIAa1LTER 4 T91Lr. IMICKNE10i MATERIAL
Agricultuml Municiol/public R
.Gcolherm�l(Hmiing/Cooling Supply) �idcmiai Woler Supply(single)Industrial/Commercial QRnidcmial Water Supply(shared)Irti tion MATERIAL EMP CEMEIcTMET1100&AM01TT
Non-Water Supply Well: n. /U-1
Moniloring Rccorcry a.Injection Well: n.Aquifer Recharge [3Gmundwaler Remcdiation PACK if WeAquifer Storage and Recovery [)Salinity Bamcr � ? aIATERIAL IMP CEMENT METH
Aquifer Test [)Slonnsveter Drainage A n• 3 R. '/ .f—or Jb '9✓L
Experimental Technology [)Subsidence Control fl. n.
Gwdu:rml(Closed Loop) QTmccr I 21L DRILLING LOG faustebaddiflonalskeb ifrReeaa
PRAM TO D[9CRIPTION taMr.hrNam wNrxet sbn a2
Geothermal(Hcalin Coolin Rclum) rjOhlicr(explain under 921 R marks) Dft. It.
4.Date Well(s)Completed- —av 4ell IDd OE
Ip n.
LD
f
Sa.Well Location: / •s-�'�""
it.
/•N, nExirtylDxrrappl.b41
Physical Address City,and Zip :,s- S
it 21.REM1f ARKS
Ohl OS_ •-? 7• Ll2 '
Cuunty Parcel lJemifisotian No.IPINI n \�
5b.Latitude and longitude in degreeslminutes/seconds or decimal degrees:
tifwcll fmW.isne Vleingissa(I'tcicei) 22.Certification: \:• \:'
35" N
S'•rntum of Ceni(IN\Yell L.rimstw Da¢
6.Islam)the wells) ermanent Or [)Temporan
Ill.�-y (/ Ill.slgnlxg IN,Joan. I berxb/�ratify tier the urlln)uns h,rrsl samrucled in xrcordawe
7.1s this it repair to an existing well: [) es to
r MKO n,*h I3d NCAC 02C 0100 w 134 NCAC 02C 02m bell Con eocnox Simriards end the,a
/(dais u a repair.fill ow knpuu uYl/eonsmwoon hlfannxrion and esplain du nnwrc oJIAr
cape nllhis rccmd her hrrn prcnided rn(he urll m,ner.
«Imir InxI"IL'/IYixnrLi stt'lloil Or on the hank r f(hisfrnm. 23.Site diagram or additional well details:
S.For Gcoprobe/DPT or Closed-Loop Grotherunal Wells having the same You may use the back of this page to pmvidc additional well site details or well
construction,only I GW-1 is needed. indicate TOTAL NUMBER of sells construction details. You my also ouch additional pages ifrs= s ry.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth Wow land surface: sCs lRJ 24a. For All Welk: Submit this farm within 30 days of completion of well
/'ar mu/rip/c uY17s Iln all drplh,ildigrwm I¢romple-36,011o'-M 2@107) construction to the following:
10.Static water level below top of casing: ✓� 00 Division of Water Resources,Information Processing Unit.
I(,mrcr/n,rf is eh v canoe,,�,o`C+,.. 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24h. For Injcction Wells: In addition to sending the forth to the address in 24a
Rotary above,also submit one copy of this rem, within 30 days of completion of well
12.Writ construction method: '7 construction to the following:
tic.uugm rumry,cable.dlrccl push,me.l
Division of Water Rtsoorcea,Underground IRjMion Control Program,
FOR WATER SUPPLY WELLS ONLY: p� r� 1636 Mail Service Center,Raleigh,NC 21699-1 W6
13a.Yield Igpm) 2 Method of Inn: 24r. For Water Suosdv & luketion Wells: In addition to sending the form to
the addr,sAcs) above, also submit one copy of this form within 30 days of
13b.Disinfection ts'pe: Amount: .ti4L)D POM completion of well construction to the county health depanmenl of tlx: county
where consimcicd.
10-6"
Form GSV-1 Noah Carolina Dcpanmcnt of Enrironmenul Omlity-Divuan of\Vmtt R sources
Raiscd 2-23201 h