GW1-2021-00252_Well Construction - GW1_20211213

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This Corso can be used-for single or multiple wells
Y.Well Contigt tot lnforrraation:
Arthur Wayne Cannady 14.wATERZONES
-FROM TO I DESMIPTION
WdlContregtorNaute 5 R �,� fL
2125-A n e. F
NC Well Contractor Certification Number t S.OUTER CASING for multi-cased wel4 R L1NER t a ll ble
Cannady Brothers Well Drilling, Inc. FR M TO I MSrt3R'n THICiQ�i6S9 MATERIAL
6o a a I A J t✓
Company Name 16.INNER CASING OR TUBING(geothermal closed4oanl
tt��11/1 ��11 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: At't:t►�1 �Q� --� ft. ft. in.
List all applicable well petnits(l.e.Couny,State,Yartance,injection,etc) ft. (L In.
3.Well Use(check well use): !7 S
Water Supply We11F FROM TO DIAME78R SLOTSIZE I THICKNESS MATERTAL
❑Agricultural ❑,M�u"ni�cipal/Public t(pd m /70 Lf In. �y v
❑Geothemlal(HWing/Cool ng Supply) q eaiiential Water Supply(single) % fL In.
❑rndustrial/Commercial ❑Residential Water Supply(shared) to,GROUT
O MA MPLA OD tP AMOUNT
❑Trri lion ft. ), ,;y1.
Non-Water Supply Well:
OMonitoring s� ORecovery
fL----Q --- t,--• ------ -
cellos Well: tL $.
❑Aquifer Recharge ❑Crroundwater Remediation 19.SANDIGRAVEL PACK a linable
❑Aquitbr Storage and Recovery ❑$allnity Barrier FROM TO MATERIAL EMPLACEMENTMETROD
ft.❑Aquifer Test ❑Stonnwaterl)minage 08 ft. 7vft. i f`a t)� Vu�
ft.
_
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach additIonai sheetslftrecessa
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION ledor,herds saWroelr rely dm etc.
OGeothenml(Heating/Co oli Return 00ther lain under#21 Remarks © fL 60 ft• gH+rYe V-,A p.
� ft. •
4.Date Well iLs)Completed: /Well WH tw
Fn9- S .rdF
mZ d fl' f dL
5a.Well Location:
IL ft.
1ft- l 3 5&
Facility/OwnerName Facility UM(if applicable)
s D fLGa
Physical Address,City,and Zip 21.REMARKS '7
..d� � Ol D
County Paul Iden ificationNo.(PiN �'r _•ri
5b.Latitude and Longitude in degreWminutelt/seconds or decimal degrees: 22.Certification: �C
(if well field,one laNlong is strmciers)
3!f`�,�65�3 k7 Nf�`' ��.3do W (yy�� o SigmamofCettified Well Contractor
6.Is(are)the weli(s): erlDanent or ❑Temporary By signing this fount i hereby cenlfy that the!well(s)was(were)constructed in accoAdance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0200(Yell Construction Standards and that a
- 7.-ls-thisa repair to-an-ekIing-we0:---0•Yes—or__VNe- - - — -coFyRfthis-record_has.beenprovtdedto the weRaumer.-- -
(fthis is a repair,fill out Anotm well construction l ornWon and explaln the noire of the
repair under 821 remart}s section or on the back of this 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 weUs constructed: ' construction details. You may also attach additional pages if necessary.
Far mnhiple injection or non matersupply urlls ONLY with the sane constracdon,you can
mibmit one form AA SUBM1TfAL INSTUCT[ONS
9.Total well depth below land surface: / Jy� V fft) 24a. Fri Webs: Submit this form within 30 days of completion of well
For mithiple wells list all depths jdorent(example.3®200'mgl2@1001) construction to the following:
10.Static water level below top of casing: �� 00 Division of Water Resources,lalbrmation Processing Unit,
If water level 1..s above easing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For iniectian Wetly ONLY: In addition to sending the form to fhe address in
r 24aabove,also submit a copy of this form within 30 days of completion of well
12.Well construction meth construction to the fotlowtng
(i.e.auger,rotary,cable,direct push,etc.) i
Division of WaterResourcM Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,INC 276994636
13a.Yield(gpm) Method of feet: 24c For Water Supply&Infection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: ALX)P pYf\ well construction to the county health department of the county where
constructed.
Farts aW-1 T North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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