GW1-2021-00849_Well Construction - GW1_20210322

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WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
I.Well Contractor Information:
Ronald G. Cannady 14.WATER ZONES
FROM TO DFS[RIPrtO`1
Well Contractor Nome ", Sb it. 0 rn..l e
2126-A Js y
NC well Conlractm Certification Namber i&OUTER CASING for aruidtasM anstal OR LINER if feabk
Cannady Brothers Well Drilling, Inc. FROM I TO DIAMETER TBICAJNFSS MATERIAL
L) s H. � - R. a r• in. P-4.I J p✓L
Company Name / 16.INNER CASING OR TUBING I&rmal HosM400
-,boa /S � FROM TO DIAMETER THICRSESS MATERIAL
2.Well Construction Permit#: Ia
Us,all oppliodde m•1f[unnnmr(un Patton,It r.UIC.Cnxn(r.State, 1"mare.rt4
3.N'dl Use(check well use):
Water Supply Well: mmoSCREEN o DumE:L sl.or slzE n11EaREss n1ATEnuL
AgTicultuml QMdmc' Oublic s 11- 5 G h a r in. O j 2 L j� pvowPf— W"
Geolhcnnal(Heating/Cooling Supply) tdcmial Water Supply(smigic) a. R- in.
IndustrinUCommercial [)Residential Water Supply(shared) IL GROUT
Ini lion FROM TO AI,AJTERIAL EMPLACEMENT METHOD&AMOUNT
Nan-Water Supply Well: n. rL r d& rN/l
Monitoring Recovery R. D.
Injection Well:
Aquifer Recharge [)Gruundwiiier Remedialion 19.SANDIGRAVEL PACK if t
Aquifer Storage and Recovery Salinity Barrier FROM TO MER ATIAL EMPLACEMENT METHOD
Aquifer Tcsl QStormwater Dminagc D R' s� It. f A, ,/4
:]Experimental TmImology [)Subsidence Control O. It.
Gcothcmtal(Closed Loop) [)hater 1 20.DRILLING LOG faffifth addltiewl states if
FROM TO DESCRIPr10N robe.Wdnm.rNVrart axne.ere
Gcothcrmal(VIcatin'Coolin Return) rjOdicr(explain under#21 Rcmnrks) a R O
U n �f) d•c.."F
4.Date Well(%)Completed: 3-q- a a Well ID#
5n.Well Location: 36 G
(c✓!I �v a u1 yb n
Facilay.'Owner Name 61 �,t FF.61ity IDN(ifxp_pllk.1,10 0. R. -
06 I t)M 8wYkaA '^�i srX-Vr/1)�- 1rs 31 n. n.
Physical Addrexs.City,and Zip 6
O
(( Yd�a S�cYL\ 21.REMARKS
Wnjr(Yr'' I Pmd WeliGcmiun No.(PIN)
_i
5b.Latitude and longitude in degreeslmmuteslseconds or decimal degrees:
(ir well Geld,one IaJlong is suriiew,t) 22.Certification:
3�0 . 9�'SaSd N_7�j' : k3159k- W gm6-4� ty—
G.Blare)the rvell(s)[3Permanenl or [)Temporary
Sigeawm orCenifird\vcll Contractor Oanc
�'�a,� flr rlgnNg rho form.I hrrsfm rrnh•rpm the nr/lls)tins pectic)farrxmared in dttordnnm
7 7.Is this a repair to an existing welh DYcs or 1. "i "Ph 13ANCAC0.C.0100 ur ISA NCAC 02C.R00 Well Consinte ion St dents and that
If this is n repair•fill out knot uvfl construction ationeaden and erpldin,he nae,ofd e copy nfrhix recent has been pronded In the urti omim
repair under 1121 rcnmrkr x,Iea or do the Itdck nflhtr fomt. 23.Site diagram or additional well details:
S.For GcoprohelDPT or Closed-Luop Grathermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only i GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: I� SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: y (R•) 24a. For All Wells: Submit this form within 30 days of completion of well
l'nr n,,Jep1e nett,tin all depths ifd fferen,Icnetele•l m200'mnl 2(lf#rl construction to the following:
10.Static water level below top of casing: �7 (ft.) Division or Water Resourms,Information Processing Unit,
(fmnvr Ir+rl is ainn,rns .v . 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 5, (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
RotaPf, above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: Rotary consimction to the following:
(i.u.augm rumry,cable,ditrcl push etc.) .
Division of Water Reworks,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY! 1636 Mail Service Center,Raleigh,NC 27699-1636
)3a.Yield(gpm) � b Method of test: ,� 24c.For Water SuDtdv&lnlectlon Wells: In addition to sending the form to
the addnv(cs) above, also submit one copy of this form within 30 days of
13h.Disinfection type: -S-?'r.�srJ• Amount: 10 s> P m completion of well construction to the county health department of the county
where constructed.
Fonn Gw-1 North Carolina Dcpanmcnt of Enviromrcnml Qmliry-Division of Wacr Rrwurcrs
Revised 2.22--2016