GW1-2021-02740_Well Construction - GW1_20210527

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WELL CON5: RUCJ,IUN RE94Rn(GWA) For Internal Use Only:
1.Well Contractor Information:
Ronald G. Cannady 1 .WATBRZO Es
PROM TO DESCRIPCroiv
Well Contactor Name 7 Q R. R• 01:14
2126-A ft. R.
NC Well Contractor Certification Number 15.OUTER CASING(for niuld-' dd*01111 OR'LINER` fa' ilehble
Cannady Brothers Well EMU , Inc. FROM TO ft.
DIAAIMR ESS THICKN MATERIAL
Q R. _e.A4 V ,na
Company Name 1__ n L ANN1ER C 1 G OR TUBING l6rr"mat rloseB Jua
2.Well Construction Permit 0: Lo a l� 7 / PRGM TO DiAMhT THICKNESS d1ATHRInL
List all applicable ttt11 consiniction permits(i.e.(I1C,Corms,State,I'ariance,etc.) N R. da
3.Well Use(check well use): ft.
U.SCREEN
Water Supply Well: FROM To I IIIAM!MM SLOTSIZE T IICKNFss I MATERIAL.
Agricultural 0Manieii;.1;Nblic R. 3.2 (L t` 1^' 8 !S -�_
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) R. R in:
lndu UCommeroial Residential Water Supply(shared) 1&'GROUT
r lion O I TO MATERIAL EMPLAC 1MT MM D rB AMOUNT
Non-'Water Supply Well: R' �.d R'
Monitoring Recovery n. R.
Injection Well: R• R.
Aquifer Recharge [3Gtoundwater Remedialion 19 SANDIG VEL PACK if ' limbic
Aquifer Storage and Recovery OSalinity Harrier FROM TO MATERIAL EMPLACEMEt¢T METHOD
Aquifer Test oStonnwater Drainage 2 0 R 3 �+ B' Xs'
Experimental Technology Subsidence Control
Geothermal(Closed Loop) Tracer 20.DRILLING1AG is"' eddltloga11i11ecb iieeaiseiy2_
Geatherrtal Hcutin Coolin Rctum Other cx iainundcrN21 Remarks ° TO DESCaiS oNi`ot°r`b"f"r'ssturoekl ma�,r+�
4.Date Well(s)Completed: J Wcll ID# 2 �} J R'
R. R.
Sal Well Location:
Facility/OwnerNamc FacilitylDN(ifapplicabic) R• R. �VP"-
Physical Addmss,City,and Zip Al 176 Cy/ R R. `�1/
21.REMARKS
' r'fuf;t:SS1C:� lei
Count Parcel Identification No.(PIN) •„f
y [777 t
Sb.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tilllong is sufficieru) 22.Certification:
6.Is(ore)the wells) BrmRnent or 011'emporary Signotum of Certifted Well Contractor Date
By signing this form,I hereby cord,that the ielip)ins(were)constructed in accordance
7.Is this a repair to an existing well: (OYes or rs idth ISA NCAC 02C.0100 or 13,1 NCAC 02C.0200 Niell Consenicrlon Standards and that a
If this is a mpair,fill out Motor ttel/constriction l annartwr and ecplahr the rawre of the , ropy of ibis record has been provlded to the cell ott•ner.
repair tmtler N21 i etnnrhu secthrnt or an the back of this fora. 23.Site diagram or additional well 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 I GW-f 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: (R•) 24a. Far All Welts: Submit this form within 30 days of complction of well
For multiple wells list all deprBs if dIfferent(erample.3 t@2n0'and 2(iT h001 construction to the following:
10.Static water lever below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
f witer Ictel is abom casing,rise"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection 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 Rcsources,''Undet7;ronad Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 3b Method of test: 24c.For Water Supply&injection Wells: In addition to sending the form to
the address(cs) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount-_ �d t) N h 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