GW1-2022-02957_Well Construction - GW1_20220301

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1.Well Contractor Infatmation;
Ronald G. _Cannady
Well 0010roctm NPlne
2126-A » R. R'
n R. k
NC Well eoffitwor Certification Number
_C_an_nady Brothers Well Drilling, Inc.
Company Namc 0 R• 130 R. t 1 In. � J v
JAJOBR
2.Well Consttvetion Permit 4. tKTVR
Urt all appUrnble urll cattsintetton permits(i.e. Cnan(yt Slaw,)arlonce,ere.) tG n. In.
3.Well Use(cheek well use): A. a In,
INol
upply Wall;
ocultural ®MtaiicipnV$ublic R. / In!, t) pvG
colhamal(Heating/Cooling Supply) E)Rceldemial Water Supply(single)
dustriallCommercial Residential Water Supply(shared) I
ri ton
Non-Water Supply Well: h. a n. {e
Rccnv tt. it
on e :quifer RechoMe 00roundwaler Remediationquifer Stomp and Recovery [,Salinity Barrier Me toquifer Test E)Stomtwater Drainage �pt� n• / R. �,ti)xperimental Technology 0Subsidence Control tt.00thennal(Closet loop) mroecr
eothermal i•lcatin oolin Return) 0iber lain under 021 R 's ® n, 9 ' n, w)$,,,Qa.,.,,L.
4.Date Well(s)Completed,,jkft ;�1�e11 IDN tIsR. R•
So.Well Location. . S n' R' s
Facililyy/Owner�Noal�mre' �l �, Facility ION(lfappl(cabic) p R. fl. rr
b9 s-r n. Jim n. ,�...
Physical Address.City.and Zip b
2a cut�
Cuunty� panel khmiflwlion No.(PIN) _
Sb.Latitude and longitude In degroWminutes/seeoods or dedmal degrees:
(if wall Acid,one Milano Is culiklenq V u 22.CertiOcetio»:
115V 5l/V/5' N 7�y a.y .31 3 y W ,;z
6.1s(nre)the wetl(o)OW/4'nent or OTempo ianature o c"i iivd w ontiWar , Date
By slgrnttg this firm,I hereby mtUy that the mr/l(s)„w-NwW crosrrrne/ed to aeawdance
7.Is this a repair to an existing well: or 3No Wth J$A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Comtructton Standards and that a
{/(his is a repair,Jill oat knotrn nrll romfMcilon i0mia►ion and explaat the nature of the roll:'q/(his retold has been provfded to the uall exalt.
ropNr nndor h21 matarks.ecttmr or on the back gfthlsforat.
1.3.Site diagram or additional well detaib:
8.For Ceoprobe/DPT or Closed-Loop Ceothernxit Wells having the some You may use the back of this pup to provide additional well site details or wall
construction,only I GW-I Is needed. indicate TOTAL NUMBER of wells cordametion details. You may also attach additional pages if necessary.
drilled: ')
9.Total well depth below land surface: L� JR•) 24s. Er,All Wellat Submit this'form within 30 days of completion of well
I•i r ntttldplc ur1Ge ILr1 all depthr(jr!(gbronr(crumple-J rr�100'anti Kt�Jno1 construction to the fb)lowing:
10.Static water level below top of eating (iI.) Division of Water Resouri:4 s,Information Processing Unit,
(/•tinter inlet is abate cashig,urc.'+.. 1617 Mail Service Center,Rnkligh,NC 2769%1617
11.Borehole diatlleteri Ds yy (in.) 24b.For IgIligilm Weller in addition to tending the foml to the address in 24a
above,also submit one copy of this' form within 30 days of completion of well
12.Well co»etruMton methods Rotary m construction to the Mlowing:
(i.e.auger,rotary,cable,direct push,cic.)
Division of Water Resources,UndeMmod injection Coatrol Program.
FOR WATER SUPPLY WELLS ONLY; n 1636 Mall Service Center,Raleigh.NC 27699.1636
138.Yield(gpm) 5 Mothod of tou:.rd,.....:..e...,-, ,, 24c.Ent�.ttltit Simnly.A)nlection Wellet In addition to sending the form to
the addroaa(es) above, also submit one copy of this fbnn within 30 days of
13b.Disinfection type: Amount% completion of well construction topic county health department of the county
whom constructed.
Form dW.l /� T I k Noah Carolina Department of Environments{Quality•Division of water its mim Ravi.cJ 2-22-3016