GW1-2022-01819_Well Construction - GW1_20220218

VdELLCOiV9T�t�CTi�I� 1 CU�4IG�►•1) of nttlfn S y.
1.Well Conttmtor Ininrinotlon;
.R.a ild Cannady
Will cor,lmcior Nam �}ft. 3 r
2126-A
NC well Coffinwor coniilemlen Nnmber 1
C91nnadY Brothers Well Dftng, Inc. fl. a�v R. � NIMMAL
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Company Name
2.Well Construction Permit N:
Ust all applttable tmU tnnstnrtvloa pwmlls It.e, , aan(y,State,Parlance,etc,) 0. R. a.
3,well Use(Check well use):
[AquirerTest
UPP Y o : w
r�R. 3 It. ►• tat. 'Ole �ya Pj/C_ �thcrmal(hleatinglCoaflng Supply) DWIdemiai Water Supply(sink) fl. fl.striallCommerciol ®Residential Water Supply(shared)ater u y ell: i��
a v n• a$� g u>r-itorin Injection e tlfsrRecharge �(hounthvnlecRomodimionlfhr 9torogo and Revery DSallairy gamier C)Stormwater Draina8o 3 0 n.wimcn►al Toolinology 13$ubsidaneo Controlthernal(Closed i.00p)th al oatin in RatumRomew"Imlain umlar 021 Ram4.Date Wells)Completed. - a Well Itm ' y d h' cJ�f3a.Well Locallont . t rat 0 A.
t Food /6 a ft. ;.y 0 R.
Fociliay/QwrwNaam rallity100(if applicable) r n' ;z5U ft. Cvo*�B��ti,..0
111 g( « P t t w f� 9' !A 2 o_.,,,� N C a.s 4 A. z5 tt, <
Physical Addwit,Chy,and zip y ;2 s 3 h. 310 h.
Cuunly Parcel Identification No.(PIN)
6b,Latitado and longitude In degreas/mlaatWeecoads or decimal degrees:
(If wall flow,ono taviong Is sumktona) I,Certification-, VAKUM
"UP
6.11(it")the well(a3�ermaRent or �'10 nary is malty o o atmetta ileac`
ib'signing rhlr Joan,i kn*two,that#Ae Fornfs)ma rmv)corw omW in actadenee
7.Is this a repair to an exlettng wetlt 0r [3No Milt I SA NCA O,tC.0100 or iSA MCAC 02C.0200 Well Conunoton Srandords and that a
If this ISO repair,fill out detour nail cat IN00lon I4rd"atlon and arplaln tiro nature of the rope of rhls record ha+been pvWdad la rite avfl ornw.
repalr ardor MN rnaonb xerllan op on the back gr1htrjom,
23.Site diagram or additional well dctallst
B.For GooprobelDPT or CloK44.00p Oeothernal Wells having tho soma You may use the basic of this pup to provide additional well site details or well
corimmotion,only I GW-i is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pog:eo if ncaaswry.
drilled:
9.Total well depth below land surfaeet 3.,� ,;(ft.) 24a, Submit this thrm within 30 days of complation of well
For m,dttpla uv)Is Ifst all dopik if d0bront/rtramp e•S(Sa1an'and ltfll► oottatruetion M!to Olicwing:
10.Static water level below top of calingl (ft.) Division of Water Retlaurotx,infermtttlon Pr+pce ing Vniq
(fuater Ietrl Is atone caring,me 1617 Milli Servtoo Center,Raltdgh,NC 27MI617
1 t.Borehole diametort ►/ tin.) 24b. ►We11st In add"I to tmnding the forth to the eddm in 14o
12.Well wriallruetftttt m...M Rotary .,,.,.....m..,,�,m con a%ntetio lse itbm thitfonowc gY of this form within 30 days of completion of well
(I,o,auger,rotary,eablo,aback push,cle.)
DhWon of Water Rut ores~,Usdtrgronnd Injaetion OetMrol Program,
FOR WATER S!)PPLY WELLS CMLYc 1636 Man alms"Center,paielgh,NC 27690-1636
13m YleW(gpm) Method of test: 24c. r In addition la sending the form to
'the addr�a(ca) abavo, also submit ono copy of this liu m within 30 days of
13b.Didafeclton types Amountt 21 completion of well Construction to the county hcallh doportmatt of the county
. whtxo conurnctod.
Form OW-1 North Carolina Department of EnyWnrrantel Quality•Division of water Rsscuteoi Ravisa.l 2.22-2016
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