GW1-2021-03044_Well Construction - GW1_20210622

Prrl�Form
WELL CQNSTRUCTf ON RECORD(G3L-1) For Internal Use only:
I." Contractor information: a i F a
Ronald G. Cannady ' '� 14.WATER7.ONF5
OM, DFSC MON
Well Contractor Namo jl�``l n, �
2126-A L fL n. w
NC Well Contractor Certification Number
IT' S;iv+ll p 11,OUTER C ING fair Uld epi •:wells OR'LINER ifa '116sli
Cannady Brothers VI�6'II � r' ;l�t�c. , TO ft41,5 DIAMtiTER In T1iICKNESS 1ATERIAL
Company Name I&INNER CASING OR TUDING lh rmsiielost -1 o
2.Well Construction Permit fE: FROM TO DIAMETER TRIM MATERIAL
U.rt all applicable rmll consanicttan permits(i.e.UIC.Cnungt State,Parlance,etc.) n n• in.
3.Well Use(check well use):
17.SCREEN-,
Wat upply Welld oM IAMETP SLOTItr ItcK—ME tATERIAL
gricultural 0MunicipaI�ilblic n. n. w In• , Q!S y(� P(J
Cicothermal(Heating/Cooling Supply) OResidential Water Supply(single) A. I It. in.
Industriavcommerciel Residential Water Supply(shared) I&GRO
Irri Sion RROIN TO 1.. , E t CE EATM M. OD AMOVW
Non-water supply well: It. n'
Monitoring Recovery n, n.
Injection Well: ft. n. I
Aquifer-Recharge — (30roundwaterRemedintion - .- 19 SANDIGRAVEL PACK Ife 'll Irk
J
quifer Storage and Recovery Salinity Barrier trttOM TO M,,A//1SRtA4 EbiPLACEMEt,T METHOD
quifer Test OStormwater Drainage J n- n'
xperimental Technology 13Subsidencc Control
othermal(Closed Loop) J3Tmccr0eothermal Heatin Coolin Return) Other(explain under#21 Remarks Ft To D9SCRJ1FnON I sollirork sire etc•
fL � fL
4.Date Well(s)Completed: 6, 1 Well IN 2 O n, z A.
So.Well Location: �`�d y a 2'` 5 n. n.
Facility/"Owner Name Facility IDa(if applicable)
�•`� S -/mac/ Go C�.u�vh to116
Physical Address,City,and Zip n.
21.REMARKS
County Parcel Identification No.(PIN) PCJ ;d ! W
Sb.Latitude and longitude in degrces/minuteslseconds or decimal degrees:
(if well field,one la ltong is sufficient 22.Certificationi
N -•78� , 6� ) 3 le w `,;iiI y"ca
6.is(are)the weh(s) rmanent or Temporary signature of certified well Contractor Date
By signing this form,I hereb)•emit,that the uril(s)was(uvre)cartstnicted in accordance
7.Is this a repair to an existing well: 0Ycs or G3bla-,' ulth I JA NCAC 02C.0100 or I SA NCAC 02C.0200 Well Consimction Standards and that a
yih s?—is a r�epain flit odl-kn�itvil cotiuhmifawlsUbnnorion and-4V oln'rhe'rtaarre-of the - .coM-of thistecond has_bectiprojided to the uvit(mner.
repair under 021 remarkv section or art the back rythis form. 23.Site diagram or additional well details:
8.ror Geoprobe/DPT or Ctowd-Loop Geothermal Wells having the some You may use the back of this page to provide additional well site details or well
construction,only I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: y51RUCTIONS
9,Total well depth below land surface: rJ' S (n) 24s. For All Wells: Submit this form within 30 days of completion of well
h'or multiple uvldt list all depihr if 190MOt(r:rampte•3 On 200 pad 2(?1001 construction to the following:
10.Static water level below top of easing: a� (ft.) Division of Water Resources,Information Processing Unit,
Uuarer level is above casing,use-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11•Borehole diameter: S�'� (in.) 24b.fgr Inig0lon Wells: In addition to sending the form to the address in 246
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,ctc.)
Division of Water Resources;Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall Service4 enter,Raleigh,NC 276"4636
13a.Yield(gpm) 616 Method of test: �� — 24c.For sSuRnly,A lnlecdon Welds: In addition to sending the form to
l�m the address(cs) above, also submit one copy of this form within 30 days Of
13b.1)fslnfection type: Amount: completion of well construction to the county health department of the county
where constructed.
Font OW-1 North Carolina Department of Environmental Quality•Division of Water Rcsourc i cs. Revised 2-22-1016
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