GW1-2021-04491_Well Construction - GW1_20210429

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WELL CONSTRUCTION RECORD(GW-I) For internal Use Only:
CA
1.Well Contractor Information: 1s��+
Arthur Wayne Cannady ei\ ;;, 14.WATER ZO
NES
FROM TO DESCRIPTION
Well Contactor Name �L1 \ 1 ft. o) rt.
J 5 V IW
2125-A r,��,o�` ft. ft. a,
NC Well Contractor Certification Number P Q C 15.OUTER CASING for mniti-ensed wells ORLINER if a Iieable
Cannady Brothers Well Drill• C. FROM TO DIAMETER THICKNFSs MATEE,A
t- ft. � ft. r in. �40 v&/
Company Name ,+,r�
��• 16.INNER CASING OR TUBING eathermaldosed-loop)
2.Well Construction Permit#: W C go - Dto/S T FROM To DIAMETER THICKNESS DATERIAL
List all applicable it-ell constriction perhits(i.e.UIC,Counn'.State,Pariance,etc) R• R• rn.
3.Well Use(check well use): R. R. in.
Water Supply 1 17.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
Agricultural Muni' UPtiblic '1 R. D ft. •• in- Q/ (� V C1
Geothermal(Heating/Cooling Supply) esidential Water Supply(single) V ft, ft. in.
Industrial/Commercial Residential Water Supply(shared) I&GROUT
irri ation FROM I TO MATERIAL EMPLICEMENT MEI7iOD&AMOUNT
Non-Water Supply Well: O ft. R. v P~
Monitoring [DRecovery
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remediation
19.SANDlGRAVEL PACK(if applicable)
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL EMPLACEIt 1T METHOD
Aquifer Test [3Stormwater Drainage b fL R. 111,4 0 1 /�!
Experimental Technology [3Subsidcnce Control R. ft.
Geothermal(Closed Loop) OTracer 20.DRILLING LOG attach additional sheets if necessary
( Geothermal(Heating/Cooling Return) Other(explain under#21 Remarks) FROM To DESCRIPTION color,hardness.soilimck in size,etc.)
R. D rt. a
4.Date Well(s)Completed:3-12-, 1 Well ID# ft' 11 ft.
5a.Well Location: AID
R. 6 tD ft.
o R.
Facci/illi-ity/Owticr amc / Facility IDN(ifapplicable) �' j} j ft.'
/
Physical Address,City,and Zip ft. ft
�3 / I.5 4)3�j UU 1 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one lat/long is sufficient) 22.Certification:
6,Blare)the wells) errnanent or Temporary Signature of crtified Well Coo mctor Date
0v signing this farm.i hereby certify that the well(s)has(were)constructed in accordance
7.Is this a repair to an existing well: es or [3No with!SA A`C.4C 02C.0100 or 15A NC.4C 02C.0200(Fell Construction Standards and that a
if this is a repair,fill out 4-1101171 well constriction information and explain the nature of the copy of this record has been provided to the tell owner.
repair antler 1121 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-i 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: 0 (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
For mnthiple cells fist al!depths ifdiQerent(example-3C 200'and?@100) construction to the following:
10.Static hater level below top of easing: 3 ,y\ (ft.) Division of Water Resources,information Processing Unit,
hfi ester level is above casing.use"+" '1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 3/7 (in.) 24b.For Iniection Wells: In addition to sending the font to the address in 24a
Rotary above,also submit one copy of this form within 30 days of completion of well
12 Well construction method: 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) IF Method of test: 24c.For Water SunDiv& Iniection Wells: In addition to sending the form to
the address(cs) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: ,200 P19w) completion of well construction to the county health department of the county
where constructed.
Form G W-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2-22-2016