GW1-2021-02485_Well Construction - GW1_20210901

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WELL CONSTRUCTION RECORD(GW-1) . For internal Use Only:
I.Wen Contractor Information: `
Ronald G Cannady 'n,1 14.WAT �N>s
�= FROM TO DFSt.RIPTt 5 '
Wcll Contractor Name J 1�1t R. R.
�,
2126-A �,:��,�.,��:�� ►;�
R.
NC Well ContractorCeriifteation Number `• J w 15 OUTER CASING for multt�eafed freitt OR LINER fa ieable
mom To DIAUtETER TpIC1,TESS� MATERIJtL
Cannady Brothers We{{ Dr{{ ng, Inc. b R. �. a,l tar. oG
Company Name: I&INNER CAS INGORTUBiNG rt�ldoseddoo AtATfRL\L
FROM To mAi1tETER TBiCKNf:SS
2.Well Construction Permit#: IL R. in
Ust o11 applicable uell conStntction permits(I--UIC,Counts srate,Parlance.etc.) tar•
fit. R
3.Well Use cheek well use): 17 SCREEN'
1Vater pply Well: FROM To D+AMETER SLOT SIZE THICK afATEv�L
..r: D R 8. P in Z P
griculturol [3Mumc,pal/�ublic 3,5 1}
g upp y (3Rcsidential Water Supply sm le In. t1�
Geothermal(Hearin Coolin S 1 ) uPP Y( g ) R. R.
Industrial/Commercial QResidential Water Supply(Shared) 1&GROUT '
FROAf TO fMA RIAL' EMPLAC EAT METHOD&AAtO1iNT
Irrigation R. (� R• UWs-
Non-'%Ynter Supply Well:
ORccoveg
Monitoring
ft. R'
Injection Well: ft. ft.
Aquifer Recharge Groundwater Remedimion
19.SANDIGRAVELPACfC f 1[eabte L\fPIA s1FNTrrET1101)
Aquifer Storage and Recovery Salinity Barrier FROM TO AtAT6RtAL
Aquifer Test
[3Stormwater Drainage 3j�
Experimental Technology
Subsidence Control R. R.
Gcothennal(Closed Loop) 13Traeer FROWS UNTO G ettiehaddltionalehe.91r�sa nshe.e,c
bFSCRIFI7ON [olor.bardaen.saNraek
Geothermal(Hcatin Coolim Rewm) nOther(explain under#21 Remarks far, a O R.
4.Date Well(s)Completed: 4etl ID# a a R• R.
R. fL
35
So.Well Location: � ) R, R,
Facility/Owner Name Facility 1Dn(if applicable)
J /W /S C :4 g� R. R.
i r -_
Physical Address,City,and ZIP 21.REMARKS
Coun r~�M r Pareci Idemific'i on No.(PiN)
5b.Latitude and longitude in degreeslminuteslseconds or decimal degrees: Meatiow
(if urll field.one InViong is suiliiciW)
e
Si aturcorccnifed Well Commetor Date
6.Is(are)the wells) manent or Temporary char the rills ns urre7 eouarructed In accorrlanrc
By stgnrng this form,I herebp Cert(6 ()n
7.Is this a repair to an existing well: Yes or t7"" wth iSA NCAC 02C.0100 or 15A MCA 02C,0200 Nell Conumellon standards and that a
U r,this is a repai fill out kamr1l,ven constructtott h formation and explain the nannre of the roFt'oJthls record has been provided id the um i ou:rer.
repair under H21 remarks seciloa or on the back of thisforot. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.ror Geoprobe/DPT or Closed-Loop Geothermal Wells hfiving the some construction details. You may also attach additional pages if necessary-
construction,only i GW-1 is needed. Indicate TOTAL NUMBER of wells StMMI77TAL IN9HUCTI04
drilled: �S —
Total well depth below(and surface: (n•) 24s. ror All Wens: Submit this form within 30 days of completion of well
9.
hor rnudtiple avlio list ail depths ffd(Qerent feranrple-3@300 and 2(a)/001 construction to the following:
10.Static water level below top of casing: Jr (ft.) Division of Water Resources,information Processing Unit,
1617 Mnil ServiceCenter,Raleigh,NC 27699-1617
U, ater leml is ahmv casing.use^+ � ./
1 I.Borehole diameter: /7 (in.) 24b.�r lniectia Wells: In addition to sending the form to the address in 24a
Rotart� above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 'l construction to the following:
(i.e.auger.rotary,cable,direct push.etc.) Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY(YELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
24c.j or taster Sunnly&infection Wells: In addition to sanding die form to
13a.Yield(gpm)_ - Method of test: the address{cs) above, also submit one copy of this form within 30 days of
�(� Amount' adf I" completion of well construction to the county health department of the county
13b.Disinfection type: where constructed.
Revised 2-22-2016
Form GW-1 North Carolina Department or Environmental Quality-Division of Water Rcsou:Me$