GW1-2021-02321_Well Construction - GW1_20210722

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CQN W- For Intemil Use Mr.
Weii Contractor Information:
Ronald G. Cannady I-E Al.-WATER ZONES :a
Well Contractor Name a'� ` oAfTO DEMC P9'1{tN
2126-A. . JUL s
tt.
NC>VeJlConttnetoiCCi{itkfitionNumlMt r C��lCif�U 3,O1TlggG"tt3gtN{E fotuuCi :trdbt'O1fLH�fER" I. bN
Cannady Brothers Wellingri C3c► vRo� To Di Ant TnetcNtss MATetttAL
Company Name ' t � fL .�Z+r; in. 0 ti
�^ 16.INNERCASING TU 1Nli. 1'
2.Well Construction Permit 6: w C 1 j — 4as sL)-5 FROM I To I D TEatAL
Of 011 alrplfcable urtl eonstnMtfaa permits Ae,UIG Caus!V.State,Narlatim etc.) fL ft• io.
3.Well Use(check well use): n• R• ln•
Water Supply Well: 17. EEN
FR M MAM, tL6 itru ATBRIAL
AgricuHumt 8Mufi'W* bite {t' 3=3 tt. a t t In. �j j � jd t1 t`✓ &-
f ttcothermal(Heating/Cooling Supply) tial Water Supply(single) ti, p. ,, out /
Industrial/Commercial 01tesidentiai Water Supply(shared) /53 "e %ea:lJaL NO
1B. O
lilt tint! FROM TO1 ! xri OD AM ttNr
` Imonitoring
an-Water Supply W41: ,� ,
1tccov
1 Injection Well: R.
M Aqui?ec Rcctiorge ` — - �Oraundwater Remediatian
19,
9 AV PACK 6 bk —-- -
i Aquifer Storage and Recovery 0Saliffity t)arrier 1:'RDh! ToMATBRlAL F1iptA HMO tlD
Aquifer Test Dstomwater Dminage h'o h• (�-d n• ► .44)
f
Experimental Technology OSubsidence Control lb Il.
! Geothermal(Closed Loop) Tracer 2L ORJLLINQ LOG fatith
' Geothermal Hernia Coolin Return) Other (explain under#21 Remarks !'soar TO ° N sera.bk - dM
4.Date Well(s)Completed: 7` Well 1D# t S'h. h.
So.Well Location: J f� tt'
r p
-� /�
FaeifitytOwtmrNatne Facility
:soft ft.
Physical Address,City,and Zip IL h
2t.REMARKS
Cauniy parcel Idaraiftcation No.(PIN)
Sit.Latitude anti longitude In degreesfminutestseconds or decimal degrees:
(if Well field,one latRong is sufficient) 22.Certification:
3
S vQ� �/y� 1f lV ! b �� � ^-� W � , j},tl
6.is(are)the welf(s)CI�nent or Temporary sigaaturcofcctt Well Conuactar Use
IT),stgntug this form I herek-crrf(6-that the xrllfs)am furre}coastntcted in accordance
7.Is this a repair to an existing well: ec-or 0No t:4th l SA NCACO2C AI00 or ISA NCAC 02C.0200 Moll Coast wilon Standards and that a
Ifthfs Is a tmpafr,f ll out knouw art/construction hqlonnation and etp/ain the nature of the . caff of thft record has been prot9detl to the tor/1 owner.
.--
23.Site diagram or additional well details;
8.For GeoprobOOPT or Closed-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 OW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages ifnecessary.
drilled: ) 60
IIItMITTAL 1 C, TI Iv
9.Total well depth below land surface: 00 24a. For All Welts: Submit this form within 30 days of completion of well
For touhfple hulls list all depths ifdtfferenr farample•3r• {ja 2 2{a�10M) � construction to the following:
10.Static water level below tap of casing: J (ft.) Division or water Retouroes,Information Processing Unit,
{Hotter tesrt fs abare casink ase *+ 3/1 )617 Mail Servk�Center,Raleigh,NC 176WI617
It.Borehole diameter: k "
(in.) 24b.For.!»icction Wei1s: to addition to sending toe form to the address in 24a
Rota above,also submit:one copy or this form within 30 days of completion of Weil
t 2.Well construction metbod:.__ ry construction to the following:
(i.e.auger.rotary,cable,direct Pugh,etc.) i
Division of Water Resources,Underground injmlon Conwal Program,
FAR WATER SUPPLY WELLS ONLY: f 1636 Mail Servke Center,Raleigh,NC 276WI636
13a.Yield(gpm) Method of test: ! � 24e.For Wabr&m eds: In addition to sending the form to
the address(cs) above, aim submit one copy of this form within 30 days of
13b.Disinfection type: Amount: Pen completion of well constructioa to the county health department of the county
!o-t .
where constructed.
Fame OW-1 North Carolina Department of Environmental Quality-Division of Water Resotirm Revised 2-22.2016