GW1-2021-02415_Well Construction - GW1_20210727

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ELL CON5JLtV!9JJQ j REC98P IGW-1) For Intemal Use On y:
1.Well Contractor Information:
Ronald G. Cannady 14 w 9
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Well Contractor Name S R. - � R.
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NC Well ComraclorCcniticationNuttaxt 1 RCASING foratul8�easW R' '1NER 1"bte
Cannady Brothers Well DrUng, Inc. Most TO DIAMETER ICKHFM MATERIAL
p rt. &C) ft. in. ptic�
Company Home B G 1 "1 CASING N
2.Well Cons(ruction Permit 0, G d IiD y 7 / M nun rat t�aaae5ss IAL
List all applicable Nell construction permits(i.e.UI.,roungt State.Parlance.etc.) rt rt: In,
3.Well Use(cheek well use): ft.
SCREFN
Water Supply Well: 17.
_ i M t! KN A IAL
Agricultural 13 - ctpalt'' is 10pn. 1 e) f1• a,t to .G/Z �d �I)l✓Geothermal(Holing/Cooling Supply) esidential Water Supply(single)
IndustrialtCommercial (3Rcsidential Water Supply(shared) ! G O
Irrigation I M o
Non-Water Supply Well: ?VRO
Monitotin Recoveryn ec on e :Aquifer Recharge 0Oroundwater Remediation rtAquifer Storage and Recovery 0Snlinity Harrier TO PAC MATERIAL EMPLACEMENTMETHOD
Aquifer Test DStormwatey Drainage 6 n• (0o
99
Experimcnial Technology OSubsidence Commi n.
Geothermal(Closed Loop) OTracer G ' s dt intialsbeeftifGwthormal Hcatin Coolin Retum Othcr(explain under#21 Remarks fL
° tI O color oewroelc «s.4.Date Wells)Completed: (' Well IDN e/an' &AVt Set.Wctl Lac//ation: p rt.
)r/-L=0. a E Z Z2 D n. 6 n. E,t,a;•t Jz.,,.d
FacilitylOwncrNnntc Facility lDN(if applicable)
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Physical Address,City,and Zip. 1 3'j) !5` ft. /S S n ?A`
1-3 p b 9 Y y b► y 21.R8MARKS oi\,
Cuunty Parcel Identification No.(PIN) �S\�
Sb.Latitude and longitude In degreestminnteslsecoads or decimal degrees:
fir well field,one lad/long is sumcle q 22.Certification:
.t3s °• �� �4zg N 7�°. �L3-2 W
6.1%(are)the wells) ermanent or Dremporary Signature of ccnifled Well Contractor ! u
0),slgting this form,l hereby culo.that the n,rll(s)rrws(inrre)eoumteted in accordance
7.Is this a repair to an existing web: �r [3140 u9th ISA NCAC 02C.0100 or 15A NCAC 02C.0200 troll Construction Standards and that a
Irthis is a ri paIn full out Amami well corivn+ction►t)fonnation and aplaht the nature of the cop),of ills record!hm born provided to the troll ox-ner.
mpoir wader H21 r ernarks section or on the both t)flhis fort+.
23.Site diagram or additional well details;
g.For GeoprobrlDPT or Closed-Loop Geothermal Welts 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 pop,
additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (11•) 24a• For AO Wells: Submit this form within 30 days of completion of well
For nnuhlple oellc Iist all depthe(f d(g'orent larannple-IQ2nn'artd 2(t+,lM construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Pr'ocessing Unit,
(f uuror level is abrnr cashig,asc"+" 1617 Mail Service Center,Rn*h,NC 27699-1617
i
11.Borehole diameter: fir 3 (In.) 24b.For Injection Wells: In addition to sending the form to the address in 24o
Rota above,also submit one copy of this;form within 30 days of completion of well
l2.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,Nc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: / 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) „^_ Method of test: r 24c.Ear Wutcr Sunnly A In gg�n wetly,: In addition to sending the font to
the a ddress es) above, also submit one copy of this form within 30 days of
13b.Disinfection type; Amount: ,,(� d pa Yt'� completion of well construction to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality•Division of Walet Rcaources Revised 2.22•I016