GW1-2021-01094_Well Construction - GW1_20210305

WELL CONSTRUCTION RECORD CW- ` For Intcrital Use Onty_
1.Well Contractor Information:
Ronald G. Cannady
� aVA `R 2,ONES::
t _ TO DBSCRIMOIN
tVdl Contractor Name ,j sf'',. c�, R, R,
2126-A ;�;�' rov 3 IL ov S
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NC 111cll Contactor Certification Number I&0lJTER CASING(for multi-ca"ardh)OR LINER a livable
Cannady Brothers Well DrUling, Inc. FROM TO DiAMEfER THlc1,'FSS MATERIAL.
rt. rt-)R. ;f•c in. k4 G)
Company Name 16.INNER CA51NG OR TUBING Iffeat -I closed-loop)
2.Well Construction Permit 0• FROM TO DiAat�F7t THICIGNESs MATMIAL
List all applicable moll consinrctian permits 0-e-UIC COURT.State.l arillum etc.) % rt' in.
3.Well Use(check well use): %
I7.SCREEN
Water Supply Well: FROM TO nuMETER SLOT Size IAL
Agricultuml llMunt4$aUPublic a a+I in. ) > P00tv-,
Gcrothcnnal(Heating/Cooling Supply) 13Residential Water Supply(single) D• R, in. C►t
Ind 'aVCommercial OResidential Water Supply(shared) I0.CROUT
rri+ tion FROM TO MATERI 01PI E�ten-ratettoD�.4�1O1t3�T
Non Water Supply Weil: ft. o R"
Monitoring Rccovgry rt IL
Injection Well: D• It.
Aquifer Recharge oGmundwatcr Rcmediation 19.SANDIGRAVEL PACK fa licable '
Aquifer Storage and Recovery Salinity Barrier FROM TO MA E.\it+i A 10T METHOD
1
Aquifer Test [3StrnmnaterDrainage J"00 R• 37 % f° �P
Experimental Tcchnolk--y [3Subsidcncc Control It. • It.
Geothermal(Closed Loop) 13Traecr 20.�DRiLL-1NG LOG attricti addttionat shee&If
P170�feator.6ardaesa.mniraek is alto.na
Geothermal(HeatingfCoolingRctum) r3Otbcr(explain under9-1l Rcmad,-s) FMNt I TO DF.SCm
R. , rt.
4.Date Well(s)Completedd_W,111D9 , R"
R, fL
5a.Well Location:
Facility/Owner Name Facilit ID"(irappli Ie) 62 0n" 7 hH"
Physical Address,City,and Zip y y �C1 21:REnIARKS 3 7R
��(�� M �SA - �
3 k
County Parcel Identification No.WIN)
5b.Latitude and longitude in degreesiminutes(seconds or decimal degrees:
(if hell field,one latllon is sufficient) 22.CertifLcation-
3 N `.2_5 y7 9 r ll' 3- / a°a1
Sisnaturc of Certified Well Contractor Datc
6.Ware)the teell(s) ermanent or [3Temporan
�� Br signing this form.i hrrebl•certh•ghat the irrl/(s)iras(urre)cotrsn'ttaed in accardandc
7.Is this n repair to an existing well: QYes or'I1J!'° u-0 15.4 NC.4C 02C.0100 or 15.4 A'C.4C 02C.0200 Irell Construction Standards and that a
I(this is a repair,fill our kaonn sell eausmectlmr information and exptain the nature ofthe -M.nftlris rrdord has been prm4ded to the troll mrmr.
repair corder B21 remarkr section or on the had-ofthis form. 0 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geotherma)lVells having the same You may use the back of this page to provide additional well site details or%veil
construction details. You may also attach additional pages if necessary.
construction,only I GW-1 is needed. Indicate TOTAL DUMBER of wells
drilled: C� SUBMITTAL INSTRUCTIONS
9.Total.yell depth below land surface: / � / (R•) 24a. For All Welh: Submit this Corn► within 30 days of completion of mil
For rmdriple%vik list all depths ijddereni(eramph,3fa12D11•and tea 1W) construction to the following:
10.Static hater level below top of casing: 5 (ft•) Division of Water Resources,Information Processing Unit,
If surer icnrl Es abmr casing,use-4- 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. % An•) 24b.For iniection Wells: in addition to sending the form to the address in 24a
above,also submit one copy of this form within 30 da)-,of completion of well
12.%Veit construction method: otary construction to the following:
(La.aueer,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail.Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) V Method of test:--� Z 24c.For Water Suntdv&Injection Wells. In addition to sending the form to
the address(cs) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount completion of well construction`to the county health department of the county
where cot►stntcted.
Form GN-1 North Carolina Department of En ironrrxntal Qw1ity-Division of Watcr Resources Revised 2-22-2016