GW1-2021-04340_Well Construction - GW1_20210408

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WELL CONSTRUCTION JUCORD(GW-I) For internal Use only
1.Well Contractor information:
Ronald G. Cannady
14.RATER t ZONES f
•^'1 a ,( e
Well Contractor Name �`� FROM TO I OFsCRIPnol.,
2126-A rt ft. G
AY�, `� 2021 �`° ft. s rt.
NC Well Contractor CertiticationNumber
+ nr n;;,;. 15.OUTER CASING(for Mal ti rnsed mflc)OR L)NER + n lintblc
Cannad Brothers W fhDr i s,;he. FROM To DIAMETER THiC1u.ES5 JiATHRL\L
�
Company Name 1n. sA yi) P
16.INNER CASING OR TUBING facothermal closed-1
2.Well Construction Permit ff• W �� i' Jl FROM TO DIA31ETEA I THICK'NMS I MATERIAL
List all applicable+rell consiniction pennies(i.e.U1C.County.Stare.1 ariance,eir.) ft. R. in.
3.Well Use(check well use): fL ft. in.
Water Supply Well: 17.SCREEN
FROM TO DIAMETER SLOTSIM TIUCKNFS$ MATERIAL
Agricultural �Municij+aUPublic Drt, SD in. b` �a PVr,1..rA
Gt.•othennal(Heating/CoolingSupply) 5A/identialWatcr Supply(single) R. rt. in.
lndustriaVCommercial OResideatial Water Supply(shared) 1t)GROUT
--Irrijuation- - --- - - FROM TO MATERIAL EMP \CEMEnTdtETtiOD&k\tOUiiT -.
Non-Water Supply Well:
Monitoring Recovery ft. R.
Injection Well:
rt. rt.
Aquifer Recharge DGmundwatcr Rcmcdiation
19.SAND1GltAtrEL PACK(irapplicablel
Aquifer Storage and Recovery Salinity Barrier FRO%l TO MATERIAL EMPLACENIM7 METHOD
Aquifer Test 0Stomwater Drainage /p C ft. /fU ft.
Experimemal Technology OSubsidcncc Control tl. fL
Gcothcrmal(Closed Loop) [3Traccr 20.DRILLING LOG(altaeh additional sheets irneecssa
FROM TO DESCRIPTIoN coign Inrdnem soiVrod:n in nine.etc)
Gcotliermal(Heating/Cooling Return) Othcr(explain under#21 Remarks) O rt. q d ft. 5"1 1d
4.Date Well(s)Completed:..7�1411111 ID9 L10 tr. f) rt. 4- )
5a.Well Location:
r:cl-i U ft. U rt.
f4 /h 6 2-7- PC,�•./ Ckrt. S rt. 1
Facility/OwncrName Facility lDN(if applicable) CI'iS % /CC) R,
,op rt.� ,luG �• ft
a°
physical Addmm City,and zip ).8'3&y /,'1 t1 rt' /SD rt' S
i So Sf 6,7 2 Qa X 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutestseconds or decimal degrees:
(if well field.one lnOong is sufficient) 22.Certificic�atitiioQn- /
N %V �1'(' t"- -
6.is(are)the welf(s)> rmanent or 0l'emporary Si are ofCenificd Well Contractor Date
� By signing this form.I hereby ceriify that the+nell(s)uus(mere)courtrtcted lit accordance
7.!s this n repair to an existing well:
QYcs or DI�. frith 15A NCAC 02C.0100 or 15.4%rC.4C 02C.0200 Ilell Constnrctioo Standards and that a
if this is a repair.fill out known aril consinterioi information and explain the nautre of the copy of this record has been prorided to the uel/o+nrer.
repair u+rder 1i 21 remarks secrioi or on the back of tliis krrm.
23.Site diagram or additional well details:
S.For Gcoprobc/DPT or Closed-Loop Geothermal Wells having the some You may use the back of this page to provide additional well site details or well
construction,only 1 G%V-1 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: ).50 (ft-) 24a. for All Wells: Submit this Corm within 30 days of completion of well
For nuthiple rolls list all depths if different(example-3@21v10'and 2@inn') construction to the following:
10.Static water level below top of casing: 7 b (ft.) Division of Water Resources,Information Processing Unit,
if ureter lc+vl h;ahm•r casing.are 1617 M1lai(Selvicc Center,Raleigh,NC 27699-1617
11.Borehole diameter: 3 - (in.) 24b.For Iniection Wells: in addition to sending the foot to the address in 24a
Rotate! above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: '7 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: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) ��a U _ Method of test: /'1/` 24c.For Water Sunnly&Iniection Wells: In addition to sending the form to
P�a the address(es) above, also submit!one copy of this form within 30 days of
13b.Disinfection type: ��,-4 Amount: completion of well construction to the county health department of the county
T where constructed.
Fonn GN-1 North Carolinu Depanment orEnvironmental Quality-Division of Water Rcsour a Revised?22-2016