GW1-2021-05283_Well Construction - GW1_20210601

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WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information: IN�1)
Arthur Wayne Canna,d C 14.WATER ZONES
Well Contactor Name I N FEM-
it,, DESCRIPTION
2125-A ��' _
pKo,aessing Ua�itNC Well Contractor Certification Number Infoir 13tiOn iSet;1,o11 IS.OUTER CASING formnI"-cased wells OR LINER ifa livable I
Cannady Brothers Well D°�Iing Inc. FROM TO DIAMETER TAiCKNE55 MATERIAL
r O R. 5 ft. yr` in. tfQ qw&
Company Name
voo� -16.INNER CASING OW BING eothermalclosed-loo I
2.Well Construction Permit#• V(J C� FROM TO DIAMETER THICMNESS MATERIAL
List all applicable it-ell construction permits(i.e.UIC.County,State.Variance,etc.) ft. ft. in.
3.Well Use(check well use): ft, ft. in.
Water Supply Well: 17.SCREEN
pP y FROM TO DIAMETER SLOT SIZE TntCKNESS MATERIAL
:)Agricultural Mun i al/Pliblic t. it. r in o M
s p �SUf ;Z 7S �!5 5s�ya 1'rJK+i
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
e
Industrial/Commercial OResidential Water Supply(shared) IS.GROUT I
Irrl ation FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: ft. ft. o t� I w
Monitoring ORecovery -
injection Well:
ft. ft.
Aquifer Recharge DGroundwater Remediation
19.SAND/GRAVEL PACK If applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
Aquifer Test 13Stormwater Drainage QL)R. �—R. q f r /G
Experimental Technology Subsidence Control ft. ft.
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additio ui sheets irne6essa i
Geothermal(Heating/Cooling Return) Othcr(explain under#21 Remarks) FROM 2. DESCRIPTION"IIL lot,hnrdoas soiUrock a pa size etc.)
o FL lac R. : &AAL SO..r, -
4.Date Well(s)Completed:$ �d "�0 WeII iD# 3 " ft' q& !c ft c5't' Fsr.s.
eat n!A
5a.Welln: T 14 ,5 i i !`. 'C.A- ►-" - lid ft. r Y ft.
LJ cl U !44
r
Facility/Owner Name ij Facility IDN(ifapplicable) 164 Cft' 3lb ft' a ham-.&_4
�:5 f Qt1s ! �� Jt3, ft. 1sc ft. y�y sa..I Rom.
` / , 4 >s
Physical Address.City, nd Zip = f ` ' i�S ft' a•� R
S ' / -7 i fl 7 a�ro 21.'REMARKS 'J�S_ — Z 4f �u I•
County Parcel identification No.(PIN) �'�'"'�so ""IQ
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees: LrJ
(if well field,one[atllong is sufficient) 22.Certification'
y JAW&
6.ls(are)the well(s)uermanent or Temporary Signature of Certified Wc11 Contractor Dale
��" Hy signing this form.i hereby cerh�that the ur/i(s)uns(urre)constructed in accordance
Imo"
7.Is this a repair to an existing well: 13Ycs or pith 15.4 NCAC 02C.0100 or 13A NC4C 02C.0200(Fell Construction Standards and that a
If this is a repair,fill our known me11 construction information and explain the nature of the copy of this record has.been provided to the null otvter.
repair under#21 remarks section or on the back of this form.
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 1 GW-1 is needed. Indicate TOTAL NUMBER of wells constriction details. You may also attach additional pages if necessary_
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 5 (ft.) 24a. For All Wells: Submit this form within 30 days of compl Lion of well
For multiple icells list all depths ifdiQ'erent(example-3@2700'and 2@ 100) construction to the following:
10.Static water level below top of casing: 5 (ft.) Division of Water Resources,Information Processing Unit,
if enter level is abo a casing,use
•1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: D 3Jy (in.) 24b.For Injection Wells: in addition to sending the form-to the a dress in 24a
Rotary
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 'l construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: n 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) y Method of test: '7 24c.For Water Supply&lniec6on Wells: In addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type: %14 Amount: .140 PP A_ completion of well construction to the county health department of the county
CC where constructed.
J
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Re%ised 2-22,2016
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