GW1-2021-04492_Well Construction - GW1_20210429

Print Form
WELL CONSTRUCTION RECORD(GW-1) 1 For Internal Use Only:
1.Well Contractor Information:
Arthur Wayne Cannad 14.WATER ZONES
Well Contractor Name O ^ red\ TO ft. DESCRIPTION
2125-A PQ Q�OJG o f. V
NC Well Contractor Certification Number ��� �$
nj���yp�,� I5.OUTER CASING for multi cased sretls OR LiNER da ticable
Cannady Brothers Well Dr � 's IC. FROM TO DIAMETER THICKNESS MATERIAL
rt. at 5 ft- I Y1 in I S'A YJ Lt
Company Name 16.INNER CASING OR TUBING eathermal dosed-loo
2.Well Construction Permit#: FROM To I DIAMETER A THICKNESS MATERIAL
List all applicable mull cotutniction pennits(i.e.UiC.Coungy,State.Variance,etc.) R. fL in.
3.Well Use(check well use):
ly Well: 17.SCREEN
NVR!��Supp FROM TO DIAMETER SLOT SITE THICKNESS MATERIAL O
:Jggricultural 13Municipal/Public Jr R. 55 rL t/l- in. .0.1S yV c
Geothermal(Heating/Cooling Supply) E)Residcniial Water Supply(single) ft. ft, in.
Industrial/Commercial Residential Water Supply(shared) 18.GROUT
Irrl ation-- -.-._. _- _- - - -. FRONV I TO ----MATERIA1.-- EMPLACEM NT-MEfHOD&AMOUNT
Non-Water Supply Well: ft. Q IL44,
Monitoring Recovery It. R.
Injection Well:
Aquifer Recharge Groundwater Remediation
19.SANDlCRAVEL PACKCif applicable)
Aquifer Storage and Recovery OSalinity Barrier FROM To MATERIAL &11PLACEDIFTT METHOD
Aquifer Test '3Stormwater Drainage 5 ft. R- fd ;/A L
Experimental Technology IDSubsidcnce Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG attach additional sheets if necessary)
FROM TO DESCRIPTION color,hardness.soiVcock rain size.etc.
Geothermal(Hc:rlin*Coolin�Return) Other(explain under#21 Remarks) 11 ft. R.
4.Date Well(s)Complete 3-a 11 We imi CJ
R. R.
5a.Well Location:
Facility/Owner Name Facility ID4(if applicable) ft. R.
1 fl 0 P'* T"" Deavt.f�n Q_ �ti�''1"`�'"'� ►y C-
Physical Address,City,and Zip
!�_' 21.REMARKS
County P tb bs Parcel Identification No.(PiN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one let/long is sufficient) 22.Certification:
I
W 441 _
3-
6,Ware)the wells) manent or 0Temporar y Signature ofC.nified Well Contractor Date
Bt•signing this form,I hereby cenh•!that the itell(s)etas(mere)constructed in accordance
7.Is this a repair to an existing well: s or [3No midi 15A NC4C 02C.0100 a•15.4 NCAC 02C.0200 Well Construction Standards and that a
If Ibis is a repair,fill out Amami it-ell consinictio n information and explain the manure of the cony of this record has been provided to the trell omwer.
repair under H21 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 construction details. You may also attach additional pages if necessary.
drilled: / SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: J (ft•) 24a. For All Wells: Submit this form within 30 days of completion of well
Far multiple a elis list all depths if different(example-3 n 700'at ttd�2 a ltN1') construction to the following:
10.Static water level below top of casing: `� (ft.) Division of Water Resources,information Processing Unit,
If water lei-el is abore casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For iniection Wells: In addition to sending 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: Rotary 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)10 _ Method of test: 24c.For Water Supply& Injection Wells: in addition to sending the form to
p,� the address(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: U 0 )7/'"/ completion of well construction`to the county health department of the county
t where constructed.
i
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources - Revised 2-22-2016