GW1-2022-01386_Well Construction - GW1_20220107

I.Wall Contractor.Information: k
Cannady
Wall contmciorNam „
2126-A S �. S- R,
NC Walt Catntoetor Coniacatien Ntmd+tr
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cannady gathers Well DdTnj Inc. L
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2,WeltConstruction ls"Wt a: M O I M rt.S 3
wl all arptttable till coasrrtretlan rermits(l.a life,cnat* State,5driance,ate) 11.
3.Well the Ybeek well uile)t 0.
stetSupplywelit
Agrieulturol M tigbliapi)
Qocthermai(HeatinglCooling Supply} dermal water3mly(single) G in
IndustriallCommeroial DRe sidentiai Water Supply(shared) LOR
1 ern
NoA•WAtsr Supply Wen; s1o0 ,Z
onittlrin Raxty it, R.
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` AV urge:--— -�CkOundvratct"Rcmcdiation� —'- - —- - — —
Aquifer Stomp and Itecove ryy ;C)9ellnity Harrier t
Aquifer Te st 08tonn%Wer Drailztge
Exparimonlal Technology DSubsidance Central'
Gwtlwml(Closed loop) " Teaser
Ciaoth al Heatin in Aetum Other lain wider 021 R � n.
P6A 0 a tvv _ 22
4.Date Well(s)Completed; Well ID# a 7 fl. R.
sn,Well Locatiotn
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FacilitylOvetwNam' 42,
Iriat ilhyl0tt(itapitlirabkl O h' Q'_
Physical Adduct.City."d Zip h. tt. " <'t -1 o
Caunty Parcel I&Millation No.(PiN)
6b.Latitude and toogltude in degreastminutestaecands or decimal degrcns:
(ir��au��a�d,one lsUMng H cufitcirni) u.CertNlmlon; ,
0.11(ore)the wep(tl) rmainent or OTemperary 918tatumorcol I COMM01 lisle
6),sipfog this firm, f Aer4y cmL&that tht tntKs)ww home)eo wnrcted In acamlanre
7,is this A repair to an Whidltg wellt 13Yel Olt Wth MA HCAC 02C.0►00 or UA NCAC 02C.0200 Well Catamwictt katWards and that a
trills ISO r epoin fill out krroun null roam ellm 1111 mallaa and«a 410 tit nature 0f►ht toff 4f rhls rmml has bcrvn pm4drd to The unil over.
mpatr under III/rvntorb section or on the bock grthtlrfu m.
-- -- — 23.Sire-diagram or apolgonat sell e3etsiktt_�
B.For GeoproWDff or Closed-Loop,Geothermal Welts having the some You may use the back of this pa(,to''to provide additional well deu6tls or well
construction,only t OW-i Is twedcd. tndieato Tt,'fAl.NUMH$R of welts -construction siorsila. You may also attach additional pages if necessary.
drilled:
9.Total well depth below land surface: 1 a � t(1.) 24e.ft-AUVAht Submit this Ibnn within 30 days of completion of well
Fnrmullok nbltt Ittt all depths(rdiftmot fara"06 jW11n'tntd')Gl0tY) oonatntotion to t t0 flowing:
10.Stalk water level below top of using, V 0 (ft.) 1)1
1V
kton of Witter ltetOtirt tnlbrmaderlt homing unit,
iYintior level is abates rasing,sera"t" 1617 Mail 13e nim Center,Rttldgh,NC 3709*1617
i 1.borehole diameter: {{n.) 24b.Mpg jjy t In addition to wdhtg the fella to the address in 24a
IL Well conetmetltm tttatbodt Rota y ab abovintalso to submittbtiowi gOng y of this tbrm within 30 days of completion of well
P.Q.au(tat,awry.cable,alnect push,etc.)
Division of Water Resources►Undergronad Injection Goatrot Program,
FOR WATER SVPP'LY WELLS ONLY: 0 163G Mail ticrvlce Center,Raleigh.NC 27690.1636
13A.Yletd{gpm) dl� Merthad of test•. n E4c. In addition to sanding the form to
M 'ihe addtass(es) above, also aubmtt one copy or�this fbtm within 30 days of
13b.Dldnketion IM: Amount: aDU F�pdVl completion of well construction to t!w county ImIth department of the county
when:cottattuctenl.
Form OW-1 Noah Carolina t)opanmmt of EnvImo nsntet Quality-Division of water i aroma Ravisad 2.23--3016