GW1-2021-04339_Well Construction - GW1_20210408

W LL CONERVC110N RECORD WMD -For-Internal Use Only:
1.Well Contractor Information:
Ronald G. Cannady n C`NI 14.WATERZONES
FROM TO DESCRUMON
Well Contractor Name
2126-A APR A 2021
NC Well Contractor Certification Number 15.OUTER CASING(for uld-eaketi welb)OR LINER Of
Ccinnady Brothers WeWOrft AL
Vp_ DIAMETERTHI
H. t3, ft. Orit in. C�kyzi 1?0(,
Company Name 16.INNER CASING OR TUBING 01hcrm4kvId%ed44oV);
2.Well Construction Permit 4:6 1 UC;tb d 6 3 FROM
TO I 111"IETER _I THICKNESS I MATERIAL
List all applicable evil construction perailis(i.e.111C.Couno,Stoic,JOriO"ce-cic-) 04 ft--. I - in.
3.Well Use(check well use): ft. R. 1W_J_ I
17.SCREEN
Water Supply Well; FROM TO I mAMU'V._"__ SLOTS= TuICKN MATERIAL
Agricultural 136 R. )y It. a 0 In-_ 6&A4.,A M p4,�/
Geothermal(HeWng/Cooling Supply) ffK-idcntial Water Supply(single) R. I I
Industrial/Commercial 131tesidential Water Supply(shared) IS.GROUT'
Irrigation FROMI TO ht AL EMPLACEMENT MFTIIOD&AMOUNT
Non-Water Supply Well: It. It. 7­5 P Ox
7)Monitoring _131tecovery
11fjeflan Well: ft. R.
Aquifer Recharge (3Groundwater Remediation
19.5ANDIGRAVELP illapplicriblell
f 211
Aquifer Storage and Recovery OSalinity,Barrier FROM TO bIATMAL EMPLACEMENTMETHOD
Aquifer Test 0Stormwatcr Drainage 106 R. y/
0-- V" PM/\
Experimental Technology [3Subsidence Control R. R.
Geothermal(Closed Loop) 07fraccr 20,DRILLING LOG lattliekad
DF-0114111 solUratit bVe.Wain size,tic.)
Geothermal(HcatingLCooiing Return) under#21 Remarks sheets If iii a+e"
FROM TO RIMP74 War.WdUtW
Other(explain It. R. 7-e)
4.Date Well(s)Completed: 3 W61 ID# ft.
5n.Well Location:
Facility/Owner NsA Facility M10(i applicable) 1156) J () d
;?SqAi/ lod ft. / is-ft.
Physical Address,City,and Z 115-ft. /Vj R. V-
ip //,p 6us 13(P 0 v 21.REMARKS
County Kra.(PIN)
5b.Latitude and longitude In degrees/minutes/seconds or decimal degrees:
(if well field,one laiLliong is sufficient) 22 C Ification:
3Y6 , rq -V W
6.Is(are)the well(s)Mfl-r-lanent or [)Temporary signatuiv of Certified Well Contractor. Date
By signing this forni.I hereby cert(fy;�that the ut-11(s)ins(uvre)Constructed in accordance
7.Is this a repair to an existing well: E]Yes or 9 i0h 15A NCAC 02C.0100 or IJA NCAC 02C,0200 lVell Constntafon Standards and that a
Ifthis is a repair.fill out knouit well construction tilfortnation and explain the nature of the copy of this record has been prmided to the%%vlf 011-11.
repair under H21 reworks section or on the back af 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 I GW-I is needed. Indicate TOTAL NUMBER of wells construction details. you may also attach additional pages if necessary.
drilled: glaycTim
9.Total well depth below land surface: T D 00 24a. For All Wells: Submit this form,within 30 days of completion of well
P'or multiple uvils list all depths ffdIffereni(example-3@2010'and 2@11M construction to the following:
10.Static water level below top of casing: L) (ft.) Division of Water Res,ources,Information Processing Unit,
Ificater ki-el is abom casing,use­+" 1617 Moll Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.)
24b.For Inlecthm Walk: In addition to rending the form to the address in 24a
.Rota r above,also submit one copy o0his form within 30 days of completion of well
12.Well construction method:
y 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: nn 1636 Mail Service Center,Raleigh,NC 27699-1 636
13a.Yield(gpm) Method of test: 24c.Far_Wat -Q­.t.A I.;lLtion Wells: In addition to sending the form to
he address(cs) above, also submit one copy of this form within 30 days of
13b.Disinfection type:.!ZJ1,:g±eZ __ Amount' 20 2 completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Rcsour ves Revised 2.22-2016