GW1-2021-04431_Well Construction - GW1_20210811

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V�F�LL CONS' '1� T,C CQRll(GW-1) F6t-Internal se on y:
1.Well Contractor information:
Ronald G. Cannady �� Ts
Well Contractor Namo Most
R N
", ft.2126-A � v ,
NC Well Contractor Ccnilication Number 1S O 6R CAS NG for atnl 'tt 1t O R eabh
Cannady brothers Well DOng, Inc. sal a Dlnnte R THI MAT@¢IAL
n 35 n. 11 ito a v
Cnmpnny Name 1 71,:
l
2.Well Construction hermit MLU Ud y s M rt at List all applicable uell constnicitan Ivrndts(i.e.tilC,Cmurry,tyatq 1arlance,arc.)
3.Weil Use(cheek well use): K
ater Supply Well: 17' t t itN MATERIAL
AL
_911Agricultural �MtaiioijtnUitublic Js n, v-S n. In• j 1(p' cv4
Geothermal(Hcating/Cooling Supply) idential Water Supply(single) " y1, In.
IndustrialfCommercial 0Residentisi Water Supply(shared) GROUTIL
Irri lion FROM r A T 1k A NT
JN,4n-Water Supply Well: © "• 10 rt.
WA
Monitod ltacove
Aquifer Recharge E)Groundwatcr Remediation 1 . O L A r
Aquifer Storage and Recovery Salinity Barrier Fao;M T A tnl E, aq Mt Titan
Aquifer Test [3Starmwater Drainage Ud"• /
Experimental Technology 13Subsiderrce Comml "• "•
Geothermal(Closed Loop) DTrncer 2&DRILLIPI "
Geothermal Hoatin Coalin Return other rat lain under 021 Remarks PROM 1 ll a a s mrk pe
4.Date Well(s)Completed: ) D al Well llm
$a.Well Location: n �
gISO
UL jj Uv� �" o a"• /3 v nMat
FacifilyiOwnerName Facility ION(ffnpplicable) 3�' lqr
Physical Address,City,and yip �-�$ 'I( It. "' ` \�
' �Sy�j-s�NJ.Uh.. 21.RBM c.St
County r� Parcel Identification No.(PIN)
VIVO,
3b.Latitude and longitude to degrees/mMutestsa:ronds or decimal degrees:
(ffwail field,one inilfong is sumc)ent) 2L Certification: 2
3s°P Sr'2.5 toy 10 N , iS3 15ro W a *S • a
6,is(sre)the well(s)i3Permanent or OTemporary
Signatuteo ilia!WcItContracto+ � Mae
� By signing this form.I herebp cert(h'drat the neil(s)%sw(mere)constructed to occordance
7.Is this a repair to an existing well: Oyes or [;Ko, Wth I SA NCAC 02C.0100 or IBA NCAC 0217,0200 Well Constrmlior Pe dardr and that a
tf thls is a mpair,fill ota knoam well constructlau Ir1lbrnation and s rplain the nature of the copy of this recarl has been prvadded to the uell maaW.
retmir under N21 remarks section or on the back elhis forru, 23.Site diagram or additienal well details:
8.For Geoprobe/DPT or Closed-Loop Geotbomai Wells having the same You may use the back of this page to provide additional well site details or well
construction,only I OW-1 is needed. Indicate TOTAi.NUMBER of veils construction details. You may also attach additional pages if necessary.
drilled: MITTAL U O S
i�.S��AtY .��C..
9.Total well depth below land surfacer tft=) Mn. ) s Submit this form within 30 days of completion of well
F'or+nnlive melds list oh depths ifd(ff—1(csamplo-i @22Mr'and 2 e@ifNr) constrttction to the following:
10.Static rater level below top of casing: (n•) Division of Water Retaurem Information Processing Unit,
(jutirer Ieael is ahow casing,aso"3/y� 1617 Mall Service Center,Rolelgb,NC 276"-1617
11.Borehole diameter: ` (in•) 24b.For InJISdiln Wells: in addition to reading 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(allowing:
(i.e.auger,rotary,cable,direct push,etc.)
Divl,ton of Water Rtasoorces Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 216"-1636
,
,
13a.Yicid(gpm) t_.°„_.'� :_ Method of test: 2dc.For Water An Mat Waits: In addition to sending the form to
the address(es) above, also submit one copy of this forth within 30 days of
13b.Disinfection type: ._-_ Amount: h>l completion of well construction Ito the county health department of the county
--- whore constructed.
Fonn OW-1 North Carolina Depar►nteni of Environmental Quality-Division of Water Ramirc ra Revised 2-22.2016