GW1-2021-06419_Well Construction - GW1_20210915

_ 9119. 5/
Prl�t�figftn
C T W- For Internal Use Only:
. 4
I.Well Contractor information:
Ronald G. Dannady tWATM ZONESr
Well Contractor Noma t I TO
att�tpN
1-3
n h.
NC Well Contractor CertilkafuanNumber 1 1S OU7>;R ! G !tiara OA L1N a bk
Cannady Brothers Well Drilling, inc. OPt TO olAPt R rHIC1tN MA RIAL
,._ of In. ,y d) p v v
Company Name ,
2.Well Construction Permit#: t"A)("7/ D j y C/ FROM I TO I
i 0 R °i 1 t
List all applicable tiell con:rnretion permits(I.e.111C,(7aungt Mate,Parlance.etc.) rt.
3.Well Use(check well use): n. h. in.
Water Supply♦ ell: 17.SCREEN
Agricutluml �MtrnicijxtU�sublic R
�t. rr ' ln.I 4D,#2 tf puouOUT
Geothermal(HeatinglCooling Supply) idential Water Supply(single)
IndustrievcOmmemial Residential Water Supply(shared) t IL GR
irri Yon r c oo a AMOUNT
fens-Water Supply Well:
Monitotin Rccovc n. tt.
Aquifer Recharge 00toundwater Remediation
1AVEL PACK(if swilit")
Aquifer Storage and Recovery Salinity Barrier i cM TO A 1"I. Pt AC M N ETHOD
Aquifer Test Stormwater Drainage D n. ILL
Experimental Technology [3Subsidence Control
Geothermal(Closed hoop) Tracer 20. ILLI e
10 Geothermal Hcntin Caotin Retum Othor(explain under#21 Remarks °Yh/)C N J uamrack aG
4.Date Weil(s)Completed: �11' well 1D0 7 R' 3 5 h'
5a.Well Location:
6R•.
Facility/OwncrNaaamc Facility lDN(if applicable)
Physical Address,City,and Zip R' ft. s.
6 e;d 13 j.z y u4) 2I REMARKS
Cuunly Parcel identification No.(PIN) ry
Sb.Latitude and longitude in degrei:Wminuteslseeouds or decimal degrees: I n"My
(if well Rc1d,one laillong is sumclem) 2L Certification:
6.ls(are)the weil(s) ermanent or OTemporary Signawro orce"Illed well Contractor Dote
��� Sy signtng this form,I hereby carry that the itell(s)nos prone)catirrnrcted in accordance
7.is this a.repair to an-existing wen:_ Dyes or tit="_ nVih!JA NCAC A2C.A100 or lJA rVCA C 02C.0200 Well Consmretio i Srandar rh and that a
(f ihis is a repair.fill out Rneun ttrrll constrarrlon lgrbrroatlon and ewlain the nature ojthe , copy grthts record has been prmYded la the weA orvr<r.-- ----- - --
reperirunder 921 rernnrks secNorr or on the hack ythhJurm. 23.Site diagram or additional Well details:
8.For Geoprobe/DPT or Closed-Loop Gcother'mai Wells having the game You may use rho back of this page to provide additional well site details or well
construction,only I AW-i is needed. Indicate TOTAL.NUMBER of wells construction details. You may also otfach additional pages if necessary.
drilled: } �TTA�11�isTRUCT1otgFi
9.Total well depth below land surface: /3 AN 24a. For All Wells: Submit this lbrm within 30 days or completion of well
For nothiplr uvl(.e list all depths if dlffemni(cromp►e.J rt�i 20 i'mtd 2@111tr) construction to the following:
10.Static water level below top of caging: (�) Division of Water Rertources,Information Prmesaing Unit,
if ulster invi is abatr cashig,nse"+" 1617 Moll Service Center,Raleigh,NC 27699.1617
11.Borehole diameter: Cln.) 24b.�1pig�ga Welit: In addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: R-o.--t—a—r-y construction to the following: j -
(i.e.sugar,rotary,cable,direct push,etc.) P
Division of Water Resources,,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY, 1636 Mail Service Center,Raleigh,NC 276994636
139.Yield(gpm) Method of test: i.�. W For Water Snmtiv&Ink$", -WAS: in addition to sending the form to
D the addresses) above, also submit(one copy of this form within 30 days of
13b.Disinfection type: /4 Amount:T _, D D 1 >flM completion of well construction I* the county health department of the county
where constructed.
Penn QW-1 dn"� North Carolina Department of Environmental Quality-Division ofWomr Resources Revised 2.22.2016