GW1-2021-03228_Well Construction - GW1_20210624

WELL CONSTRUCTION RECORD lCW-1) For Internal Use Only: Print
I.Weil Contractor Information:
ED
Ronald G. Cannady Goal 14.WATERY.ONES' l
Well Contractor Name OM TO DESC i?rT N
2126-A ��lN sing unit `t 4 ".
NC Well Commdor Certification Number �ntt3(17''atlGn�'fc1�8� h, h, €
MIN R5ec,ron I S.0 UTE R CAS I N G forrnti}tl:taierlwe}ts OR LINER fifa table
Cannady Brothers Well DrWing, Inc. FROM I TO DIAAI R TNICi.'NESS I MATERIAL
Company Name (0 X, )? In. Ll ('
16.INNER CASING ORTIMING(gooth closer!
2.Well Construction Permit#: FROM I To I DIAMIETER I THiCKNEss I MATERIAL
Wr all appl►cdble nntl construction permhs(i.e.UIC.County,Slate,Parlors,Cie.) IL h- in
3.Well Use(check well use): h• h in.
Water Supply Well: 17.SCRBEN
FROM TO DIAM TSITHICKNESS MATERIAL
Agriettlturo) ®Mutiicijiai%i'ubiic 4 tYe`ir_ g b R t' in S y� ytj f'(./(,, Jm)kly
Geothemal(HcatingfCooling Supply) �idential Water Supply(single) �J h' h, in.
lndustrial/Commercial OResidentiai Water Supply(shared)
1&GRO
firs tion FROM To TER( L DI1`LAC ERTMErnOD/4 I0V"
Non-Water Supply Well: h. lt. D�, P 0tA
Monitoring Raeovcry R. ft.
injection Well: A.
Aquifer Recharge OCrroundwalcr Remediatioa 19.SANDICRAVEL RACK(ItairtlLmlitel
Aquifer Storage and Recovery (3Salinity Bonier FROM I TO MIAWRIAL I MPLACEMMIT METHOD
Aquifer Test OStonnwater Drainage 'IL) h• .5 h, / fi a / IL'
Experimental Technology Dsubsidence Control h. R.
Geothermal(Closed loop) 13TMccr 20.ORILLING LQ(i a(W It additionalsbeeta"itdit"ssi
Geothermal N ooliqj Return) Othcr(explain under#21 RcmasksJJ FRoatI TO DF.SCR) ON r.hanlacrosaWrark xtmetc.��� �.� � p C) h. r� cD h. LrQ ,
4.Date Well(s)Completed: } .@.�_ Well Ill# aL' t}h, -3 Z) ft. m t
So.Well Location: 3 oil- S h•
3 Sh,` h,
FacilirylowngName Facility lDH(ifopplimble) qIlh.
j�?�!"M �� 1 GT�G RA 1 L� Z 1 ( f d �ft.
Physical Addncss,City,and Zip o ^).�. 3 $ h• h•
21.REMARKS
County parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minuteslsecauds or decimal degrees:
(if well field,one)avian#is sufficient) 2L Certification:
,1�!. to 3 3 Y�, Y 3 E-6 _W ��&dl
6,is(are)the welt(s) ermanent or OTemporar'y Sr#natum of Certified Well Contractor Date
By signing this Joins I heresy smyr Tart the nelf(s)uns Prer el corrstnreterl in accordance
?.Is this a repair to in iAsting*c- -13Yes- or with 1 SA-MCAC 02C.0I00 or)$A MCAC 02C,0200 tVdi Conaructfon Standards and that a
IIrthis Is a repair,fill our knotnr nril cons(mcdon tnjornation and,aptafn the nature of the cW of this record hos been prodded to the url/oumr.
repair rattler 421 remarks,section or on the hark ttf thisjarat.
23.Site diagram or additional well details:
8.ror Gcoprobe/UM'or Closed-Leap Geothermal Wells having the same You may use the back of this pale to provide additional well site details or well
construction,only I OW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMI7TAI.INSTRUCTIONS
9.Total well depth below land surface: �`� _Aft-) 24a, For All Wells: Submit this form within 30 days of completion of well
hlar nuthfple ue/0 list all depths jdiQer cut(arample-1@200 and Zoo 1111r) construction to the following:
10.Static water level below tap of casing: (ft:) Division of Water Ret aurces,Information Processing Unit,
ljunter level is abrrrr cosbrg.tare"+" 1617 Mai}Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: _(in 24b.For Injection Wells: in addition to sending the fort to the address in 24a
12.Well construction method:
Rotary above,also submit one copy of ithis fort within 30 days of completion of well
(i.e.auger,rotary,cable,direct push,eie.) construction to the following:
FOR WATER SUPPLY WELLS ONLY: Division of Water Resources,Underground Injection Control Program,
1636 Mail Service Center,Raleigh.NC 27699-1b36
13a.Yield(gpm) 'U f 6 Method of test _.— 14c For Writer sSupply&Iniection Wells: In addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: D a il) completion of well construction, to the county hcahh department of the county
where constructed.
Fort t w_l North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016