GW1-2021-00405_Well Construction - GW1_20211230

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1.Well Contractor Information:
Ronald — Cann„ ldy ,
tYefl Contractor Nome 9 �,
2126-A
NC Walt Commator CovilAmton Number
Cannad,y Brothers Well DrIHIng,Inc. o R, ,�
Company Norm
2.Weil Comtruction Permit 6:
Liar all appll<able tretl coann/cvlon pw 11$(1.e, J oluta,State.1'0rinnm Cie.) IL R. Ia.
3.Well Use(thetit well use)-
stet supply wicill
1000thmi
ulturoi MuniaijmV�'ublia R, fi. y s' ta. p1s **4 YO
mmal(Heating/Cooling Supply) 13Ilcoldamrol Water Supply(single) R,
riaXommerciol [3Rcx)dential Water Supply(shared)
lion
star sunldY tail:
lorin Racav n. n.
an Well,
fer Recharge �f3rotinthvatcr Retncdiation
fer Stomp and Recovery C)Sallnity Barrier n
ferTesi C)StotmwataDrainage AID R' 9� tt• 'Y¢u 1 P.rt�
rimental Technology �Subsidance Control
hermal(Closet Loop) from
e
Haali in Ratum a ialn under 021 Romsaits
(
4.Date Well(s)Completed) _Z.,e,.�-2'1 Well iDN t) 0' n' &&tie
So.Well Loentiont 3 a a" 33 ft' "L3ww
tom'` s
m1 ,�
Faelli►y/owmr Name
d I /as+ollhyy;ION(ifapplicable) y�R' s 7 R' •�� 4 S
Physical Addrrit.City.and ZipCAD R'
Cuunty Parcel Idwiflee/sttlea No.(PIN) E C 3 0
6b,Latitude and lonli tudo in deSpe"lminutcsfsseamis or dedmvil degrees: ,
(irwall new,ono liviong b$11molam) v 32.cor1Ifkallont fit' v 44GUNrY
6.t_(s nrOillewell(o) _. nnrent -or OTomporary aremtu c-aw et cwit"Of "°"��"`'"
rim
-- --Bp algnli>R ih(r ft►ii+t�f her+ebpi+e"rri�4�hcrlh�rr�eR(al nos hre++Nzmutrucrediaoeco►eMneo-- --
f 7,is this a repair to an existing Weill EDyss., r L3No +t91h i!A NCAC 02C.0100 or JJA NCAC 02C.0100 Wa111(hnarnrsrtew Sondan t-d that a
If fills it A repair,Jill Dill Motet.ttetJl tontlratl(on 110P111400o and GV14111 lh¢MUM 0f file cW of his lrrovfdrA to fA0 KtiN onm..
ropalr nndor BN mtiorAs xecltan or rot the back gflh0ja►m. 23.Site diWom or additionat:well details.
B.For Geoprobe Dtrr or Closed-Loop Geothermal Weds having$9 cams You may use the bask of this pugs to provide additional wall silo downs or well
construction,only 1 OW-1 is needed, Indicate TOTAL NUMBER of wells consttactian&-toils. you may also attach additional peon if necessary.
drilled: C�
9.Total well depth below land surtaeat ` 26 240. gjLAjjVWkt Submit this Barn►within 30 days of completion of well
Far mVidple nvilf I tl all dopli t(fd proot fammple.3!(f1,100'amf (li l00) comtruetion to flee nolbow(ng:
10.Static water level hetaw at fAelnal " (ft.) Dit4stan of Water Netaurt�l,tfttorlintition Prat sing Unit,
(f emtar total is above cnthig,,dn•"F" 1617 MAN Service Center,It ll,PIC 27699■1617
11.Borehole dintnetert �► % (in.) In addition to Ming die form to the addt+cat in 24a
ave bo ,also submit ono copy of this!tbrn within 30 day,;of completion of well
12.Wa1i tonstructlan m6thod: Rota .�m.._.� .s., cronomiltion to the(Mlowing:
(i.e.ouget,twary.cable,direct push,etc.)
Olwislori of Water Raoarca►Uddtmgt'annd Iq{stttoa Coatro!Progreso.
FOR WATER SUPPLY W61I.LS ONLY. 106 Man Service Center,Ro Mgb,NC 27t1491636
13a,Yield(gpm) _.�... Method of test: 24e.Rot Water SeLnnly InkefbtiA Wtdi><t in addition to sending the fame to
IN wwross(ca) above, also oubmb;ono copy of this (hint within 30 days of
13b.Dislnleetlon type: 5XI;� Amount, 2 completion of wail construction to the county health depanmant of the county
where constructed.
Revl,ed 3 3a-xUt6
Fonn GW1 North Uorolino DePaHnwnl of Snvfronmttntsl Quality.Division of waxer ttesouroae