GW1-2021-02454_Well Construction - GW1_20210811

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; �t O�y RECORD IGW 11 for Into rnat Use Only,
t Contractor tnrarmadon:
Ronald G. Cannadx 4WATER .
!JIMI TO VAMEMPI,
W��"//yyell C/�/ynlracta Nome S R�
it Cantracler Ccrlificpiian itnmtrcr is.—
.0 C tiN f ! 0 tale
Cannady Brothers Well Drilling, Inc, t AiA11i ctcn 1N!► IAL
R. G� R. Ifila, � iw Z
Camjiany Nomc l G 0
2.Well Construction Permit 0:,oG 2] ye� �d � at o s cart
List all applicable tmil constrwilva permits(i.e.VIC Cnan(n Rate.1'arinnre,eta) n• tt• in
3.Well Use(check well use):
t
alit uppiy�Vi ell: .SCRE
MUM L
Agricultural A. tr. k la. I �� G
Geothermal(Heat'ing/Cooling Supply) �8,ersidential Water Supply(single) �n, p, la, I v y p MAOF
IndustriaUGommerciai [)Residential Water Supply(shared) 1 0 t) T
[ct 'on . . O g .L t 6ME O A NT
•Non•Water'supply Well: n• n• t,
Monitorin Rccove n tt,
Injection e tAquifer iteeharge E)Oroundwater Remediation
AC
Aquifer Storage and Recovery DSalinity Harrier tROM TO 'MA Al. & Rt ETHOt)
Aquifer Test [ StormwaterDrainege (t. !t. Y a d r
Experimental Technology DSubsidence Control n. n•
Geothermal(Closed Loop) DTMccr 29p tt e
Geothermal Hcalin Caolin Return Othcr c lain under H21 Remarks 6
4.Date Weil(s).Completed: 11)' Well IN J i<• 4/ n• bG�.�
Sn.Weil Location: n' AlS tr. M ' k
T�eci1�i yJpwacr tkmc . :. -Facility iDH,�if®npptkabic) " . R• tt.. .
Physical-tlddresi;;Ghy,and yip
c73 a3 y 3 r b r�j�� 21.REMARKS
County i otcci idemirmmion No.(PiN}
y.y,,�i>]�` C yr•`O�
Sb.].iatitade and longitude in degreedminntedsecamb or decimal degrees: , Q
{tf�< u Reid one iatnong s AlA cicnl) 22.CCrillicatlon:
sy` 676156 N -79 6, ass 1��b W w,U11 �U
AIs(are)the wells) emaaent or OTemporaty Sigrtat rc of C od woU Cantrono+ ►mtc
p�q� fij•stgnbtg this farm,I hereby cord,that''the nvilis)ins hire)constnrcted in accartlance
7.Is this a repair to an existing well: DYes or GM with 15.4 NCAC 02C.0100 or 1 SA NCAC 02C.0200 Ifell Com liwilon Srandartts nod that a
(!this is a r ertr.Jill out bioun tilell conatruciroa l tformation and aplain the name of flit ro10'of this ceca t has beery prmNded to she writ outrer.
retmlr ender HN remarki section or on the black of this form.
23.Site dittgrr►tn or additional well tietalls:
8.For Geoprobe/DPT or Closed.-Loop GvAhermal Wells having the some You may use the back of this pap tU provide additional wall site details or well
construction,only i t3W.l is needed. Indicate TOTAL NUMBRR of wells construction details. You may also ankh additional pages irnecessary.
drilled: 11URM{1`iAt.IiVST ONS
9.Total well depth below land outface:,,,. .s (R•) 84e, >Far Ali Wciis: Submit this form within 30 days of completion or well
FtwNeuhlple»tilt list all depthsfrdi ercnt(trample.3@20n'and2@tnM conattuctionto The following:
I
10.Statle water level below top of casing: 15 (R•) Divisktn of Water Resources,Information Processing Unit,
� �� later,R,alelgh.RIC 37549-16f7
11.Borehole diameter. (tn. Ibt7 Mail Service Center,
outer fcsri is above town rest"+ u
24b. or lefectioa Wel s: in addition to sending the font to the address in 24a
Rota $y ,form within 30 days or complction or weii
above,also submit:one copy of this'
12.Well conalrnetian method: construction to the following:
(6e•Huger,rotary,idol,direct pwh,eta) Division of Water Revourcm U
ad Injection Control Program,
FOR WATER SUPPLYWELLS ONLY: 1636 Matt service Cc er, leigh.NC 276"-l636
t3a.Yitgd(gpm) -f Moth"of test:_ _,,, 2�• to > 11�Y � WM:'In additionto sending the form to
the G&msa(es) above, also submit one copy of this form within 30 days of
13b.DiainfeMion q pc: � -+� Amount: �p completion of well construction to`he county health depanment of the county
/ where constructed. �
Fotitt'r3W.i North Carolina Departnmm of Envitomm�tal Quality.Division orWater Resources Revisal 2.22.2016