GW1-2021-02312_Well Construction - GW1_20210709

CONSTRUCTION RECORD(GW-D For lnGim Use only:
I.Well Contractor Information: Vi l
Ronald G. Cannad _ t4.WATERz°N1x `
Well Contractor Name
t FROdt TO . DFSIrITIQr
�'
2126-A - ,
JUG I,�ntt R'
pco�e�sing R. It.
NC Well Contract"CatificationMinim �fl{�+(rn' s{SeCiiO� 35:OUMCASING formulti.asedarcUs ORLINER fa llcable
ML
Cannady Brothers Well DnMng, Inc. FRoat n. To 5 n. �r to.D9 MUMMT16tt - ,
b 8 pl/�L
Company Namc 16.INNERCASiNG OR TUBING Icocd-1
2.Well Construction Per tI:�x� �.+ t RQrt TD DlAittbT£n TNit t►'AESS :: ,tATERtAt
List all applicdble tW11 consirnction permlis lt.e.{1C. quay:State,1'ariancc Mc,) n'
R. IL in.
3.tItrcil Use(check well use):
17.SCREEN•
143cothermal
ater Supply Well: FRo�I TO DrAM rstzs T/ttt;tsNM atAT£ntA4
Agricultural �Muri It[ritbiic � t'R. tt. t• in. 012. T r✓U
Geothermal(HcotiaglC-ling Supply} caiial Water Supply(single) to
Industrial/Commercial Residential Water Supply(shared) I&GROi3 t: ;
Irrigation FROM TO itt TB IAL &�iP £htEhT atECitOD&AttOUarT
on-Water Supply Well: R. R.
Monitoring Recovery
injection e _+ —., _� _ - --- Fnost � T n. t11A7ERt _
Aquifer Recharge 00roundwatcr Remediation
19.S,lND1GRAVEI:FACK If e
Aquifer Storage and Recovery OSolinity Barrier AL l tiPLlCEitlt7tTAttiTH00
AquiferTcst OStarmwnterI)rainage rJJr1
Experimental Technology [3Subsidcncc Control
Geothermal(Closed Loop) �Tcacer 20:DRILLING LOt; .ttae6 aildn&t"nst'dm t if
(Hcati Conlin Return) Other( lain under 921 Rcmaft) Faost R. To n tmox Caton sbtvrtrctc„ tuna stsc.eta
VG
4.Date iVell(s)Completed: VBdI tD# �.' R' � R' E,n�ra
Sri.Well Location: IL
_ ,�
lam"
FaeilityfOarm Name Facility IDP(ifapplicabtc)
��� I G��t, ,�� Rtr ��o�t,.li�►•�� n. n.
Physical Address,City.and Zip 2 gas R. 4.
-�•`'=yy��` y(c Q 4 c 1�!y�i y f. al.REMARics .
Coutm• Parcel identification No.(PIN)
5b.Latitude and toagitude in degteastmtautesfsecoads or decimal degrees.
(if well field.one hillonb is sufficient) 22.Certification:
? �3 N -?�� '*/5 Jr W WA 2--d-1
6.ls(nre)the%vcIl(s)Gre<nent or DTemporary Signature ofCenified Well Contractor V BKC
By sigafog this fora t hcreb)•Cerro,that the uWl(s)ups(acre)cmtstnrctcd in accordance
7.Is this a repair to An existing well, -0Yes or• mlth 15.4,tC•iC 02C.0100 or 1Sd XCAC 0_7C.o200 tree Construction Standards and that a
_ _ __ skis iecord has bceie rorfleiro the trr11 oumr.
if this fs a re/xttr•fill alit kncnnr ire7i constrtmtion iafbnnartaranda thrnantreof ho- C°PY°f _ __...p_
repair tinder 1121 mnarb section or at the back ofrhfsfarnr. 11 23.Site diagram or additionat'wetl details:
S.For GeoprobelDPT or Closed-Loop Geothermal Wells having the some You may use the back of this page to provide additional well site dowils or well
construction,only i GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additionsl pages if necessary
drilled: SURAI1�• TAL}INURVCnOt+-IS
9.Total well depth below land surface: / Y iR•) 24a. For Ail titelis: Sut►mii this Corm within 30 days of camplaion of well
Farmalifpresrttc list all deptlutfdtj/'error;crrmpte-3@2ti)D'and 2e@1tilt) construction to the following:
10.Static water level below top of casing. / (R•) Division of Water Resources,information Processing Unit.
trintter haft is abort cortrtx;use-+ 1617 Mail Service Center,Raleigh.NC 27699-1617
11.Borehole diameter. (in) 24b.For Injection Wells: Ind addition to sending the form to die address in 24a
above,also submit one copy of this form within 30 days of completion of Weil
IL Well construction method: R(�icZ construction to the fallowing:
(is,.auger,rotary.cable,direct posh.ctc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: I636 Mail Service Center,Ratcigh,NC 27699-1636
13a.Yield(gpm) 13 Method of tew.�_.� 24c.For Water'S� "h-&Ld'teetion�Yeils, to addition to send"mg the fore to
the addresses) above. also submit one copy of this form within 30 days of
13b.Disinfection type: 25:9te Amount: � ��r%. completion of well construction to the Coady health department of the.county
where constructed.
r
Form Grip-1 North Carolina Department of Emtirontrrcntal Quality-D•ivision of Water Resources Revised 2-22-3016
f