GW1-2021-04306_Well Construction - GW1_20210430

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WELL,CQ NSTRIU(TIT RE n]R((QW-1) Foi Internal Use Only:
1.Well Contractor Information:
Ronald G. Cannady n. \ as r 14. ATERZONES
DESCRIPTI
Well Contractor Nnmc FROM TO ON
2126•A � � v R R.
�r�h Or)+L1 0
,,,.• rr. R. )
NC Well Contractor Certification Number �vr f f r !(`t tit ill
+� �1 ) 15.pt)TfiR CASING for rritilNKmsmf:roretls OR I;iNER f a {lcable
Cannady brothers 11WeDr V�l WT t1t1C- FROM TO DIAMETER THICKNESS MATERIAL
In. q_� P OL)
Company Name
16.INNER CASING OR TUBI rother"ma1 osedd
2.Well Construction Permit 0: Cr/� 0 C AD d FROM I TO I Di METER THICKNESS MATERIAL
List all applicable spit consinic ivis perodis(i.e.11I17,CaantY,Stare,Variance,etc.) n• n, in.
3.Well Use(check well rase):
17,SCREEN
Water Supply Well: FROM TO DI M ERI SIDT51YE I TI ICKNESS MATERIAL.
Agricultural 3-tDft. �.. In. ,Dls a�l„t{ Pl11JCtJ"�Iv �yY
Ocothemtal(Heating/Cooling Supply) entia!Water Supply(single) R• n• ga
IndustriaUCommercial Residential Water Supply(shared) ILL GRQ T
Inrigation FROM I TO M TERIAL EAIP MENTM-MOD4 AMOUNT
Non-Water Supply Well: n. a ft.
Monitorin Recovery R. R.
Injection Well.:
Aquifer Recharge Groundwater Remediation - —
19.SANDIGRAVEL PACK f a,'li4nbli
Aquifer Storage and Recovery OSalinity Barrier FROM I TO MATERIAL 1PLACEMEAT METHOD
Aquifer Test OStolmwater Drainage ? 3 a 1)n. /� d 'JIpaw.,
Experimental Technology C)Subsidcneo Control
Geothermal(Closed Loop) 13Tracer 20,DRILL•IING LWOG if ntmaw
Geothermal Hcatin Coolin Return) Other(explain under i/21 Remarks FROM TO DESCRIPTION ratan hsrdaers sotvreek r In Cie.
_71�o
4.Date Well(s)Completed: l� L Well IDN 3 0 !l fl 'r C"
50.Well Location: 0 'Lb ► ft fLf f fL
Jrs n, tat R. Go s
Facility/Owner Name `T Facility IDN(if applicable) fl R'
)1 llJ c GRA� C "A.A RJ Cf!2T!h N
Physical Address,City,and Zip D,5,-3 2,Sr tb 7`D R �p yr.I.tRf
'-cr.-ri. ,,,•.�. t9 /o 0 3�L/o(r 7 A I 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,one tat/long is sufficient) 22.Certification:
,15d- y 9-Q. S N -7 117 VQ,J(
6.Is(are)the wells) ermanent or [3Temporary Signature of certified well Contractor a Date
b)•signing this form,I hereby cert(j,eltat the nil/(s)ups(wire)constructed In ace once
7.Is this a repair to an existing well: Oyes or udTh I SA NCAC 02C.0100 or I SA NCAC 01C.0100 Well Construction Standards and that a
{/•This is a repair,fill out known urll construction Information and erpfaln the oature of the • coin'of this record has been provided to the uvil owner.
repair untler'NI/irinoi'ks tecTiaiior on the'Azick r7jthis`forn.— -- --
23.Site diagram or additional well details: — --
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the some You may use the back of this papa 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: S11$M(TfAL, STRUt;-F101YS
9.Total well depth below land surface: �b f(R•) 24a. For All Wells: Submit this form within 30 days of completion of well
1•1orinithiple ueNs list till depths t(di event(crmnple•j@20o,Wad 2@1(9)1 construction to the following:
10.Static water level below top of easing: LS a (R•) Division of Water Resources,information Processing;Unit,
9,110ter level is above casing,,ire"+' 1617 Mail Service Center,Raleigh,NC 216"-1617
i
11.borehole diameter: (in.) 24b.For Iniecgn Wc118: In addition to sending the form to the address in 24a
t']Otar�� above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: Rotary� '1 construction to the following:
(i.e.ouger.rotary,cable,direct push,etc.)
Division of Water Resourees,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) / Method of test: 24c.For Water Sunnly&lnlectlon Wells: In addition to sending the form to
the address(cs) above, also subritit one copy of this form within 30 days of
13b.Disinfection type: Amount: JDD PO completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Re ource$ Revised 2-22-2016