GW1-2022-06164_Well Construction - GW1_20220620

W Lt,CONST RU' CT10N RECORD. For Internal Use ONLY:
This form can be used for single or multiple wells
1.well Contractor lnfor mad' N4
Arthur Wayne Cannady 14.WATER ZONES
FROM TO. DFSCR:PTION
Well CotirsctorNatde. f4 � fL
2125-A ft ft.
NC Wdl ContractorCcttiGcationNumbcr' 15.OUTER CASING for multi•wtil wells OR LINER f n Ilcabie
Cannady, Brothers Well Drilling, Ind. FRonl tL 7YJ. .' DLiMj fbS R+n THICtCN 'F AfATER1AL
Cornpany Nellie, 16.INNER CASING OR TUBING Neat[ at closed-loon)
FROAT I TO DIAMETER I THICKNESS I MATERIAL
2.Well Construction Permit#: ft. ft, In.
Liss all applicable Well permlu(I.e.Coon(y,State,Variance,injection,etc.) ft. ft. !b.
3.Well Use(c6 (well use):' 14.SCREEN.
Water. y Well: FROM TO DIAMETER I SLOT SIZE THICKNESS I MATERIAL
ricultural ❑Municipai/Pubiic 7G� n (eft. r In. �01S yU PL)
❑Geothermal leating/Cooling Supply) ❑Residential Water Supply(single) R. ft. tn.
❑lndustriaMoeimercial (]Residential Water Supply(shared) 19.GROUT
0117ri lion AT FROM TO, MER EMPLACEMENT HOD @ MOU
` fL fL / Iiyiti'
Non-Water Supply Weli: ��Ec rL
OMonitoring ORecovery
---— njeetion Well,'. --
❑Aquiftu Recharge- OGroundwater Remediation 19.SAN11/GRAV IM,PACK if„ livable .
ClAquifor Storage and Recovery OSalinity Barrier FROM TO MATERIAL' . FINIFLACEMENT ATE77100
OAqulfer Test. OStormwaterDrainage' AIR. ft, I
I 4-., J� r17�f
OExperimental Technology. ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if gecessar
OGeothermal(Closed Loop) 07'racer FROM TO DESCRIPTION(color,henlnns,sell/rock type,arela six etc.
DGeothemtal(Heating/Cooling Return 1301h er(expIainunder#21Retmarks b fL lz rt. Tf
�. 0 47L_ /2 f L 3 t) R (J iw s 11.4-t.v t1(s
4.Date Well(s)Completech Well IDIi
5a.Well Location:' _ fL 7-� ft.
r L� ��i2 f" t�s fL R. s —J
Facility/Owner Nnnre: Facility ID#(ifapplicablc) A. fL C1 1�e2�1/�a
Physical Address,City,and zip 11.12EIIitUiKS
5
County Parcel Identification No.(PIN) J U N 2 !1 2
5b.Latitude and Longitude in degrees/iaioutes/seconde or decimal degrees: 22 Certifi
cation: ii
(if well Hold,one latllorg is sufficient), no Ur
�ti
Certified Well Contractor Date.
6.Is(are)the well(s): CAptrrmaltcnt or OTempor Ary By signing this form,I hereby cerlo 11wi the well(s)war Over.)cautrucled in accordance
��,/ with!SA NCAC 02C.0100 or 15A h'CAC 02C.0200;Yell Consiraclion Staneards aril that a
7.Is this a repair to an existing well: ld•Yes or ❑No copy ojthis record has been provided to the im.11 ooner
lftlds it o}opatr,J7!(out known nvcll conrinrction h!/ormarlan and csplain ttm rehire ojdte
repair under 021 remarks section or on lire back ofthis fornn 23.Site diagram or Rdditltm.al well detativ.
You may use tine back of this page to provide additional-well site details or well-
8.Number of wells constructed: � construction details. You may also attach additional pages if necessary.
For mndtipie hyecllon or non•irater supply wg1v ONLY with die same consavellort,you can
snbridt one farm. SiJBMITTAL INSTUCITONS.
9.Total well depth below land.surface: �� (ft.) 24,1. For All Wclls: Submit this form within 30 days of completion of well
For andrip/e wells list all depdrs(fdaureni(exampla-3®200'wO2®100') construction to the following:,
10.Static water level below top of casing:. S y`J (ft.)
of Water Resources,Ittformwtion Processing Unit,,
.jfmaler level Is above carving,use"1" 1, 1617 Mail Service Center,Rnleigb,NC 27604 617
l I,Borehole dlnmeter: J (in.) 24b.Eon in�ction Wells ONLY. In addition to sending the form to the addr&,s in
24a above,also submit a copy of this form within 30 days of completion of well
12.Well construction method: y construction to the following:
(i.e.auger,rotary,cnble,direct push,etc.):
Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 163E Mail Service Center,Raleigh,NC 276"-1636,
to I 7.t) (I-�JIZ a ForWater Supply.&. ection Wells:
13a.Yield(gpm) !S Method oftcst: 24
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount: jr—,21) well construction to the county health department of.the county where
constructed.
p.T'
Form OW-1 North Carolina Depmtn=t ofEnv"anteat an:d Naturaf Resources-Division of Water Rcsourccw Revised August 2013