GW1-2021-07062_Well Construction - GW1_20211129

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Arthur Wayne Cannady 14.WATER ZONES
FROM TO I DESCRIPTION
Well Contactor Name /g It. eff ft. u�s'a! ANd
2125-A fL fc
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a Ilcable
IA
Cannady Brothers Well Drilling, Inc. FROM ft. fL DIAMETER m. TMCKNEss MATERL
o
Company Name 16.INNER CASING OR TUBIN (geothermal dosed400
FROM TO DIAMETER THICKNESS I MATERIAL
2.Well Construction Permit tt:E/Yi I'o��'.5�.? ��✓C.�� ft. ft. in.
List a/J applicable well permits(l.e.County,State,Variance,Injection,etc.)OOp/dl fL ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public R R m / A
ILI
❑Geothermal(Heating(Cooling Supply) Affligidential Water Supply(single) R- ft.
01ndustrial/Cotnmercial ❑Residential Water Supply(shared) 18.GROUT .
FROM TO MATERIAL EM CEMENT METHOD&AMOUNT
0-Irrigation fL fG t' /Okla
Non-W_aterSupply Well: -
❑Monitoring ❑Recovery
Injection Well: fL fL
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TQ. . I M6UNAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier O fL ftI Y9
/ A
❑Aquifer Test ❑StorinwaterDminage fL ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothemtal(Closed Loop) ❑Tracer FROM TO DESCRIPTION fcolnr hardness soillrnck a rain siz etc.
❑Geothermal eatin Cooli Return ❑Other(explain under IM Remarks ft. / R- S a C
4.Date Well(s)Completed:11/,174al Well ID#
�' rL /� fL NV -
Sa.Well Location: p f ft It. r�
�'['/Q e//yify Aa/7 ft.
Facility/Owner Name Facility 09(if applicable) f`
f,59��'��u�sll�` fL fL ,
Physical Address,City,and Zip 21.REMARKS
�AAL/,fbA, �S• ��7t�rS�Q7� U, is ai.v ..•,. �...
County Pa=1 Identification No.(PIN)
5b.Latitude and Longitude in degmeslminutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
,o /
tL!• �/. -?I J9 /�G N / ,47/,p�J? O G Jr W
Signature of`CeiiifiedJVell Contractor Date
6.Is(are)the well(s):6re_..eot or ❑Temporary
BY signing this form,I hereby certify that the weJl(s)was(ivereJ constructed to accordance
___ -wjth15A_NCAC_02C_.OI00 orJSA NCAC 02C_0200{fell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or E31Vo copy ojthis record has been provided to the'ivel!owner
If this is a repair,fill out knmrn well construction information and explain the nature of the
repair under S21 remarks section or on the back ojthis form 23.Site diagram or additional well details:
,[� You may use the back of this page to provide additional well site details or well
8.Number of wells constructed- /J� construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the some construction,you can
submit ore form. A SUBMITTAL INSTUCTTONS
9.Total well depth below land surface: "t (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ijdijferent(example-3®200'and 2@1100') construction to the following:
10.Static water level below top of casing: !J UP Division of Water Resources,Information Processing Unit,
Ifwater level is above msing,rise' 1617 Mail Service Center,Raleigh,NC 2 769 9-1 61 7
11.Borehole diameter: J / (m.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Q�G!r 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: � ,J 1636 Mail Service Center,Raleigh,NC 27699-1636
J*d13a.Yield(gpm) Method of test. � �ay a 24e For Water Supply&Injection Wells:
a Also submit one copy of this form within 30 days of completion of
13b.Disinfection type:_514eip N r Amount //p/%y� well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013