GW1-2021-00545_Well Construction - GW1_20210219

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t "' WELL CO,,,NSTRUCTION RECORD(GW4, R E C vi_ aal Use Only:
1.Well Contractor Information:
Arthur Wayne Cannady 14.WATER'ZONES
+_`__nation TO DESCRIPTION
%VcIl Contractor Name CIN S CY+ ft. (0 ft
2125—A �" ft. It.
NC Well Contractor Certification Number 1S.OUTER CASING for multi•caset!wells)OR LINER if a lieable
Cannady Brothers Well Drilling, Inc. FROM TO DtM1EI ER THICKI%TSS MATERIAL
Company Name 16;INNER_CAS G OR TU131 G)e in. a)
1 �a ,_ � othermal closed-loop)
2.Well Construction Permit# -N2� - FROM TO DIAMETER THICKNESS MATERIAL
List all applicable u-ell ronstniction permits(i.e.UIC.Conan'.State.Pariance.etc.) ft. ft. +n.
3.Well Use(check well use): R• ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER' SLOT SIZE THICKNESS MATERIAL
Agricultural [3Mu
m o cipal/Public s ft. 6o ft. � 1+
-Geotheral(HeatinglCooling Supply) esie ntial Water Supply(single) ft. ft. in.
Industrial/Commercial OResidential Water Supply(shared) 18 GROUT
-)Irrigation FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: R. 1170 .ft. `�.QZ P A 4/50
Monitoring ORccovery ft. ft.
Injection Well: _
--- - --- — - - -Aquifer Recharge Groundwater Remediation !9.'SAND/GRAVEL PK`AC da appl
icable)
- -' ,..
Aquifer Storage and Recovery 13Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test [3Stormwater Drainage
Experimental Technology OSubsidence Control R. ft. 01
Geothermal(Closed Loop) Tracer 20.`DRILLING;LOG attach additional sheets if necessary)
Geothermal(Heating/Cooling Return) rJOthcr(explain under#21 Remarks) FROM TO DESCRIP fI N fcotor.hardness.wiurvck rain size,etc.
Q ft. i
ft. -)
4.Date Well(s)Completed: �a��' Well ID# R' 1-30
R' ' L
Sa.Well Location: fL (S M
ft. ft.
s (
FacilitylOwncr Name Facility ID#(ifapplicable)
ft. ft.
/+ 600,11if-tw'► � S rU G It. ft. -
Physical Address,City,and Zip y ?�8,5 ft. ft.
d 3 9 5 5 03 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lattlong is sufficient) 22.Certification'
3 S , v 3 J c� rN_'1 S 1 cl 3 3`/ W A��
6.ls(are)the-*vell(s) ermanent or Temporary Signature of Certified Wdl Contractor Date
At,signing this form,I herebp certifj+that the urdl(s)was(it-ere)constructed in accordance
7.Is this a repair to an existing well: [3Yes or with 15.4 NCAC 02C.0100 or 15A NC4C 02C.0200 Well Consinucrion Standards and that a
- -
lfrhis is a repair,fill out knout a el/construction it onnation and explain the nature of the Copt'of this record has been provided to the uell ou7ter.
repair under 021 rentarks section or on the back of this form.
23.Site diagram or additional%vel(details:
8.For Geoprobe/DPT 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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: eoC (R-) 24a. For All Wells:'"Submit this form within 30 days of completion of well
For nathiple t+rlls list all depths if different(example-3 a 100'and 2@ I00') construction to the following:
10.Static water level below top of casing: 1 7 (ft.) Division of Water Resources,Information Processing Unit,
ljwater Iml is about casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
� 3�Y
11.Borehole diameter: (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Rota above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: n' 1636 Mail Service Center,Raleigh,NC 27699-1636
fa 1 J �"` 24c.For Water Supply&Injection Wells: In addition to sending the form to
13a.Yield(gpm) Method of test: g
the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: a F� completion of well construction to'the county health department of the county
where constructed.
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016