GW1-2021-02296_Well Construction - GW1_20210722

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WELL CONSTRUCTION RECORD fGW 14 For internal Use onir
1.Well Contractor information:
Ronald G. Cannady 14.-WATER ZONES
1VcA Contractor Name
OAt VESCRIMOAi
KC Well Commetorcertiliea►ion Nunftr �Lt c ilQn ?
w
gurrn
y�r tS:Ot)T&RCASt11tG farmtriti-cased: etts t)R
LtNER rt t�rble ;
Cannady Brothers WeR ' 406g, Inc. FROMTt: DiAAiETER MESS AtATER41L
Company Name
d fL 3 05rm r l in Sys t fGJ t1 Lf
�^ 16.INNER.CASING OR.-TUBING Germtl"dtircd -
2.Well Construction Permit#: C 9. b D DU.17 X' FROM TO DIAMETER •rat MATT— 111.
List all applicable iMi consarnetion peraths 0.c 111C Comm.State Irariance,etc) iL ft. is
3.Well Use(check well use):
11'ater Supply Well: FROM TO I DiAAt sL0 siz6 I TnicKtims NSAWR►AL
A},nicultuml �Mun►crpaltPtrblic R. �� in. 0 D
b. zj �-5 say (1tX,w
Geothermal(HeatinglCaoling Supply) esideMio!Water Supply(single)
lndustriaKommercial Residential Water (shared)�r �PP1Y( IE.GROtri' .
hTi tiafl FROM TO MATERIAL EAIMCEMEN METROD&AMOUR
Non 1Vatcr Supply Well: 3 n• ;l 0 #a[A Pet,,,- P1.U' .
m,onitorint# _- _ _Recovery R. ft.
Injection Well: R. It.
Aquifer Recharge 00raundwatcr Reme diation 19:SANDtGRI►VEL PICK `I cob e
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL LNIPLACEMEta'rAIETROD
AquiferTest 13StonnwaterDrainage _150 n• isko ft. /�+° �i PA.
E&perimental Teclnfology oSubsidence Control
Gcothermal(Closed loop) 13TM= 20;DRILLING IAG attiieh adJiUnnai'shee4t if
Gcothctmal(Hcatin Cooling Return) 1301her(cx lain under 921 Remarks) FRoat r° DFscna ax tmeaaas,�rui octc
d.Date Well(s)Completed:(1,,— �'�� Well ID# 90 R. I•7 S M 9 c" F-
5n.Well Location:
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Facility/Owner Name Facility ID#(irapplicattle) x
)9S tG 3
I 4S
R. 2..S'7 ft. 0�7;,
Physical Address,City,and Zip 7tfr3 Ir Z ;z 5 7 it "�✓3 d it. C,a�
rig
9 Q s d 2•7 A 3O 21.REASAAK3
County Parcel Identification No.{PIN)
5b.Latitude and longitude in degreestm{Dutestseconds or decimal degrees:
(if well field.one laillong is sufficient) 2L Certification:
6.!s(nre)the well(s) ermanent or OTemporary
SiVatureofCcrtiliicdWellCont ¢tor -.� tc
t3 th I$A-N-AC0 httr0100 IS that the.0200,rell rarest)ctlancomaucred n tandthat
accordance
_ _ ,p signing this form 1 h cer
7,Is this n repair to as existing w¢I!i nYe: or �No - - - dC a2C.03Q0.IYerlCorarnrcgan Srgndards mat tear a
if this is a repair,fit(out immm tire11 cons►ntetlott teefantmttaa and explain the nature of the ' F +the urtt oua>er
repair ureter(121 rsmtorks section or an the back of thisfarut 1, 23,Site dlogram or additional well details:
8.For Ceoprobe/DM or Clonal-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only I GW-1 is needed. Indicate TOTAL NUMBER ofwells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL IiiSTRUCTIONJ
9.Total well depth below land surface: 3 (�) 249. For All Wells: Submit this form within 30 days of completion of well
For rardtiple uvlh list all depiht if different/emmpte.3 tit?Ittt'and W a Imo construction to the folloming:
10.Static water level below top of easing: j Gra t7 00 Division of%Vter Resources,information processing Unit,
lfatwrer lent is ahow cosiirg:use-+" 1617 mail Service;Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 24b.For litlecdokr Walls: in addition to;sending the faun to the address in 24a
Rotary above,also submit one copy of i►is form within 30 days of completion of well
12.Well construction method: ' construction to the following:
(i.e.auger,rotary,=bfc,diw gusto,ete.)
Division of Water Resource',Underground Injection Control Program,
FOR WATER SUPPLY tVELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699.1636
13a.Yield(gpm) v Method of test: j 24c.For Water Swp1v&infection in addition to sending the form to
the addresses) above, also submit one copy of this form within 30 days of
l3b:Disinfection type. r Amount: �O P-P completion of well constructs l to,the county health department of the county
where constructed,
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Form GVV-1 North Carolina Department ofEntimnmcntal Quality-Division of 1Yotcr Rem m4 cs Revised 2-11-2016
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