GW1-2021-00841_Well Construction - GW1_20210322

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WELL CONSTRUCTION RECORD(GW-1) For Intcmnl Usc Only:
I.Well Contractor Information:
Ronald Q. Cannady 14.WATER ZONES
FROM TO D6CNPf10N n
Well Contmetor Name R. R. Sa•t.,.Y�
2126-A ft. R
NC well Contractor Ccnifiation Number 15.OUTERCASING furmttki•nnsl wells OR LINER(of lirabk
Cannady Brothers Well Drilling, Inc. FRDxI TO DIA.wETEA TNICNNFS x1ATEiiIAL
0 R- 3 5 "• 01- Ib y/a uL
Cnny+am'Name 16.INNER CASING OR TUBING eloard-
FROxt TO DLLHETER TRICIu\ESS )1.\TFRIAL
2.Well Construction Permit R R id
Lut all applicable dell emalmctiaa permits li.e.UIC.Canon.Wtr.1 arioam,Cc)
R R. ice.
3.Well Use(cheek well use):
17.SCREEN
Water Supply Well: _ - Faaw TO MAaIErER LC ME nueNNrss }tATER1A1.
AEricuttural �Muni<ijnVPublic 5 R. � R �V in ^O�L t/f3 a11C�
Guolhcmlal(Noting/Cooling Supply) aiJwlwl Mala Supply(single) p. R to.
Industrial/Commercial [3Residcmial Water Supply(shared) IL GROUT
FROM TO b1ATERL\L EAPLUCE51ENT METHOD8,6T1 nNT
Imitation n.
Nun-Water Suppy Well:
Monitoring Recovery
Injection Well: n. R
Aquifer Recharge OGmundwata Remediation 19.SANDIGRAVEL PACs: d ble
Aquifer Stooge and Recovery DSalbtity Barris Faoat TO suTER1AL ENPL\CG\IL1T\IETROD
Aquifer Test
QStormwater Drainage n• n- •� /b L
Experimental Technology DSubsidcnec Control n. n.
Gcot6amal(Closed LOOP) [3Trac r 21L DRILLING LOG attach atlNtMad wheels if ccasary
FRO.\I TO a.-.,-I-•bNem•saat^rt rto<••ricl
Gcath\mmal(Heating/CnOlinc Return) r101ha(u lain under 921 Remarks) R. / R �f0.�
4.Date Well(s)Completed: .?7 z Well IDP 1� R C3 R /'t
ft. n. /. C•dtu/)R
5a.Well Location,
J.
Facint IDe lif liable) R. n. -
F'ailiry;O.omTNamc >' aPP
355 3 M ,C��Fa*•� 'f�G R R
Physical naan� .c Cll, �na Zin
n..V,it y,.nKti' 21.REMARKS
h V73-f/ 3• d/`�/
County Peal Id-raifeutiva No.(PIN)
5b.Latitude and longitude in degredtldnates/secoods or derimal degrees:
(if\,ell field.ottc IWI.ng is saRicwa) 2L Certification:
.32/` . 9 JJ 4rnoa
Sigmtum of Certified Well Contractor Date
6.Is(1re)thewelgs) ermanent or C)Temporury
m�`'/ signing rhu form. I hereby cerlifj'thaw the nrll(sl utu lame)rwmmcted!n accordancegy
7.Is this a repair to an existing well: ar [3NO .*h 15.4 NC,4C 02C.0100 or 15.4 A'C4C 02C.0200[Veil Construction 9audards ad that n
/lNus isa nynir.fil(rwr bwua urll coawract/on ir)fornrotion sad aplain the nrnare afrhe coT'nftbu recwdhmbemprmidedmrhetmltauner.
reJmir under'N2i rcntarks swoon or on don bad of tbls fW'm- 23.Site diagram or additional well details:
8.For GeoprobelDPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER of wells
cOnswetion dewils. You may also am ch additional pages ifnecesmry.
drilled: 40 SUBSi17TAL INS7RUC'1'IONS
9.Total well depth below land surface-. A) 24a. For All Wells: Submit this rum within 30 days of completion of well
Far ma7tiplc„ells list all drT'rbs ifdiffnent remmple-31n'W'and 2.Cn/ODI construction to the following:
10.Static water level below top Of casing: / (ft.) Division of Water Resources,Information Praccwing Unit,
If ante,In'e(Is ahnc oaring. 1617 Mail Service Center,Raleigh,NC 27699.1617
11.Borehole diameter. (in.) 24b.For Injection Wells: N addition to sending the form to the address in 24a
Rotar�� above,also submit one copy of this form within 30 days of completion Of well
12.Well construction method: '1 construction to the foilosving:
(La.anger.many,able.duct push,etc.)
Division Of Writer Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh.NC 27699-1636
13a.Yield(gpm) t Method of test- 24c For Water Supply&loom ion Wells: In addition to sending the form to
� y the addrws(cs) above, also submit one copy of this forth within 30 days or
13b.Disinfection tv c: Amount: '�f�-) P ll n y\I completion of Well construction to the county hcolth depamnrnt of the county
where conswcted.
Form G1t'-I
Nanb Carolina 0.yaamat of Em•ironmcnLsl Quality-Division of Water Rcsourc s Revised=2--0i6