GW1-2021-00351_Well Construction - GW1_20210721

�wn
WELL CONSTRUCTION RE •RD ,
NORTH CAROLINA
EnWronmental Quullty
•rm GW­1 Well Construdon Electronic •
North Carolina Department of En\Aronmental Quality
April 1,2021
Submission ID#
GW1-2021-00351
Are you submitting a printed form?* r Yes
F No
CONTACT INFORMATION
.........................................................................................................................
Contact Name* Email Address*
Ronald Cannady [e-mail]
Is this a revision to the form you have previously submitted?
r Yes F No
WELL CONSTRUCTION INFORMATION
.........................................................................................................................................................................................................................................................................................................................................................................................................................................................
1.Who is installing these wells?*
r Owner r Well Contractor
1.Well Contractor Information:
Certiticate# Cert Level First Name Last Name Company Name
2126 A RONALD CANNADY CANNADY BROS.WELL DRILLING, INC.
2.Well Construction Permit#:
WC20-000155
List all applicable well construction permits(i.e.lVbnitoring Wells,UIC,County,CCPCUA etc.)
What type of well is this?* r Injection Well r Non-Water Supply Well
C Water Supply Well(includes irrigation wells)
3.Water Supply Well* r Geothermal(Heating/Cooling Supply) r Industrial/Commercial
r Irrigation r Municipal/Public/Community
r Residential Water Supply(single) r Residential Water Supply(shared)
r Wells>100,000 GPD
4. Date well was completed and ID#
Date Well Completed* Well ID# Well Yield
6/23/2021 65
(gallons per minute)"

5.Well Location
Facility/Owner Name
Taylors Bridge Fire Dept Facility ID#
(Required) (If applicable)
County* Parcel Identification No.(PIN)
Sampson 15103932002
Physical Address* Street Address
871 Peterson Rd
Address Line 2
City State/Province/Region
Clinton NC
Postal/ZZp Code Country
28328-0983 us
Latitude* 34.9171920000 Longitude*-78.3646406000
Decimal degrees Decimal degrees
6. Is(are)the well(s):* r Permanent r Temporary
7. Is this a repair to an existing well:* r Yes r No
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form.
For multiple Geoprobe/DPT or Closed-Loop Geothermal Wells having the same construction,only 1 GW-1 is needed.
8a. Indicate TOTAL NUMBER of wells drilled: 1
9.Total well depth below land surface:(ft.) 9a.What is the depth of the casing from ground
343 surface?
Formultiplewells Iistall depths if different 313
(example-3@200'and 2@100') in feet
10.Static water level below top of casing:(ft.) 11. Borehole diameter:
100 8.75
If water level is above casing,use"+" in inches
12.Well construction method:
r Auger r Air Rotary r Cable Tool
r Direct Push r Mud Rotary r Rotosonic
r Other
13. FOR WATER SUPPLY WELLS ONLY:
13a.Yield(gpm)
65 13a. Method of test:
If applicable air
13b. Disinfection type:* 13b.Amount:*
sterilene 200ppm
14.WATER BEARING/FRACTURE ZONES

From To Description
313 343 sand
in feet in feet
15.OUTER CASING(for multi-cased wells)OR LINER(if applicable)
From To Diameter Thickness Material
0.00 313.00 4.00 sch40 pvc
in feet in feet in inches
17.SCREEN
From To Diameter Thickness Material
313.00 343.00 4.00 sch40 PVC wrapped
in feet in feet in inches
18.GROUT
From To Material Emplacment Method &Amount
0.00 20.00 enviroplug 3/8 pour
in feet in feet
19.SAND/GRAVEL PACK(if applicable)
From To Material Emplacment Method
275.00 343.00 1/8 to 1/16 pea gravel pour
in feet in feet
20.DRILLING LOG
From To Description (color, hardness,soil/rock type,grain size,etc.)
0.00 20.00 clay sand mix
in feet in feet
20.00 75.00 black clay
in feet in feet
75.00 180.00 coarse gray sand
in feet in feet
180.00 210.00 sand clay mix
in feet in feet
210.00 220.00 white clay
in feet in feet
220.00 310.00 coarse sand
in feet in feet
310.00 313.00 clay
in feet in feet
313.00 350.00 coarse sand
in feet in feet
21.Remarks

well drilled to 350FT,screen stopped at 343FT
22.Site diagram or additional well details:
You may upload additional well construction information here.
pdf only
CERTIFICATION INFORMATION
....................... ................ ............
*rJ By signing this form, I hereby certify that the well(s)was(were)constructed in accordance with 15A NCAC 02C
.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy of this record has been provided to
the well owner.
23.Certification*
OW
Signature of Certified Well Contractor
Submittal Date 7/21/2021