GW1-2021-00310_Well Construction - GW1_20211220

'DELL CONSTRUCTION BAG SRO N- 1Only
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I.Wait Contmetor information;
RM-a!d G. Qjnnedy
Well Controotor Noma
2126-A 3vA
n. R.
NC Well Comrootor Corlillat W Nunaror
cannadY Brothers Well Ming, Inc. �, �3 �, tn.
Company Name (� y P L
2.Well Cogstt'ueton Naratill 6t�
List at1 q/tnflrnbk troll eatrstnn"',perm a(t.e, 11r,Count).,%ate 'nrlance,Cie.) IL R. a,
3,well Ust(cheek well use), ^. ft. la,
I
upp y a t • (aijtaV Pvctmmtl(Ncating/Cooling Supply) cw o"WI al Watersupply(single) R.fisycommerciol [3Rmidenital Water Supply(shared)
ter up y ail: n. d e)an e ;
or Recharge [3Oroundwaler Remediationer Stomp and iiomcry, DSolinity BarrierMf
erTest E)Stormwater Dminsgo a D 4. Pu--
imontal Toohnology 06ubsl4ence Control n. Renml(Closed Loop) racerormal Hoatl In Return of ar Salo uida N21 R s U
4.Dille Wells)Convow: �,,_ gam_ Woti!DI) D R• 3 U R• /)')
on.WCII titont ..3 b R' -3 R'
Faellily/OwnarNamQ. RaailhylDN(Ifappileeble? n. fl.
Phylleal Addrr+.t.Chy.and Zip 3��. A. It. ' - ►'
County Pawl idantiticetian No.(PIN)
8b.Lotitttdo And longitude 1n degrcos/mtnutea/strevsads or dedmal degrees. "
(if wail neid,one laviong to tul'Aoitnt) ,Cerdticntlon; a
6.More)me welt(g) rmanent or OTemperary ftwum o omraetar tzar
a ng rAk I hereby cert�'shot the nN►ry)was Ansel eouvnuNrd In accanlanev
d1'
7 f itlti A 1 allAlt r0 pp CStit� WC11T Yet Ot' At�' — u I Orm"MCAt`IO;AI00 a-1 J4 NCAC 02C:0200 Well C Q1hRgfo`a Siaadardt end thit n
(!this is o rlpalr.JIIi out kaolin avll conjoyNfsU Iti/brnrallon tend eaPlaln the nrtntre of the copy afthls rmrd has been pro l6d to rM HvI1 omw.
rgxtir ender t01 reniarb Section or on the boat gfthlr jmm•
23.Site tNagrAm or Addttktatd well dtdrtibt
R.for Gooprobe/DPT or CI*K& oop Cleotheml Walls having the same You may use the book of this pogo to provide additional well site details or well
construction,only 1 OW-1 Is needed. Indicate TOTAL NUMUR awells osnsttuctton details. You may also attach additional pages If rteaeasary.
drilled;
9.Total well depth below►aw surfttcet �-3 th'J 24a. rl n All I Minh this lbrm within 30 days at completion of wall
Nor multiple iWis 101 all depths(f dobrvtti(etrample.3@20n'rmlt IW) aanatntMipn tot following:
10.Static water lover below tap of casingl �5 (N Division of Water lieaoutrss,lnlbM611110n i`rotftng Unit4
a'unrer fete!Is aholy rashrR,ury"+" 1617 Mail"ea tenter,Raldgh,NC 37699a1617
11.Borehole diameter: ..._.(In.) Ub,JAtJAkgWLftht in UWI tic n to tmnding the fonn to the address in 14a
Rota rtbovo,also submit ono copy of this lbrm within 30 days of completion of well
12.Weil coastrttetlatt tttethedt ..�.,,��...,.�.,.,,,.. ,..., construction to the following: I(i,o.aw.Mary.cable,direct push,etc.)
Division of Water ftworeas,Undergreaed tttlectlen Costrol li mram,
FOR WATER SUPPLY W61.L5 ONLY: i636 Mail Service Contvr,Raletgtr.NC 27bgtl463ti
13a.Yield(opm) .s Mothw of test: , 24c. In addition to sending the form to
'the tvas(aa) above, also loom t Iona copy of this form within 30 days of
13b.DislafeeiMtt type;&Z d Amsnhtti ZOO/ /v completion of well construction 16 the county health dcpanmmt of the county
whrn trortsututcd.
Form OW•1 North Caroline Depsrlmtnt of @nvl'ronm"ld Qusllly•Division of watts Rewurcve RartSat s 22-3016
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