GW1-2021-03043_Well Construction - GW1_20210622

WELL CONSTRUCTION RECORD�GW- For internal Use Only:
1.Well Contractor Information:,rr
Ronald G. Cannady t,no, 2021 14.WATER ZONES
as FROM TO I DESCRIV17ION
Nell Contractor Name
R.
2126 A
f4�; i;^v11 Y
f. FL
NCNcllConaactorCeili(imlionNumbcr
IS:OUTER CASING farmultrarsed:wetls OR LINER in' fieable
Cannady Brothers Well DriRing, Inc. FROM TO DIAn1E(ER THICKNESS MATERIAL
R. f �✓] pa
L
Company Name16.INNER CASING OR TUBING theratal c osed-lo
2.Well Construction Permit#' FROM TO DIAMETER THtCKi<FS5 titATER1AL
List all applicable treil construction permits(l.e.111C County.State.1'arianoe,etc) A. R. is
3.Well Use(check%veil use): R. tt. itt
\Vatc u ly\\rcll: 17.SCREEN
PP FROM TO DIAMETER SLOTSIEE TttICKNESS MATERIAL
gricultural 0MuiticipaOublic 03att. ISa n. r in.j 0/ BSI tJGures.+•-
Geothermal(Heating/Cooling Supply) 131tesidential Water Supply(single) p R, in
lndustriaUCommercial Residential Water Supply(shared) IL GROUT
Irrigation FROM TO - MATERIAL EMPLACUIEN-rMEINOD&AMOUNT
Non-NVater Supply Well: R• fr. �
Monitoring Recovery
Injection Well:
Aquifer Recharge Groundwater Remediation 19-SANDlCRAVEL PACK if a "tiedbte
Aquifer Storage and Recovery [3Saliniry Barrier FROM TOO MATERIAL EM CEMENT METHOD
Aquifer Tcst E)Stotmwater Drainage lX�B R• v A&
Experimental Technology [3Subsidencc Control n• n
Geothermal(Closed Loop) 13Tmocr .20.DRILLING LOG attach additional sheets if '
Geothermal(Hcolin ing Return) nOthcr(explain under 921 Remarks) FROM I TO DESCRIMION(color.hacdoas soitimek t)Vr.grain tire.etc.)
x1 ft. 0 ft 6_11 r
4.Date\Vell(s)Completed: -3 ��\Nell[D!1 3fl t). ir
Sn.Well Location: R. job fL
v� R• � � it. �x
cz�
Facility/Owner Name P— Facility ION(ifopplicablc)
PaAJVA
Physical Address,City,and Zip R R.
c, 21.REMARKS
Cuuniv Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minntesiseconds or decimal degrees:
(if well field,one lotllong is suf iciem) 22. ertifieation:
35b, v23g;k�6 N —7ff� . `� ffo3 W �� )Ld
6.is(ore)the well(s)oaetlanent or [:)Temporary Signature ofCcttiftcd Well Contractor Dfitc
By signing this form.I hereby eenifp that fire nrihs)ens(trcre)constructed in accordance
7.Is this a repair to an existing well: QYcs or 23ALP/ Wilt 15A NCAC 02C.0100 or 15.4 NCAC 02C.020011 Well Corstnrction Standards and that a
ljtiris is a repair•fill out known well cmtstnrcilou lnfortnarioa and erplahr the nature of fire cop3'of this record has been prodded to the uvil oumer.
repair antler 1121 remarks section or on the bark ofthisforrrr. 23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the some You may use the back of this page to provide additional well site details or well
construction,only 1 GW-I is needed. indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS,
9.Total well depth below land surface: `S (R•) 24a. For All Wells Submil this form within 30 days of completion of well
For nuthiple hills lixt all depths ifdITemnr lerample-3 a 200 and 20a/Rol construction to the following:
10.Static water level below top of casing: 3 J (ft.) Division of Water Resources,information Processing Unit,
!f vvrer level is above casing.use-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: /r (in.) 24b.For inicction Wells: In addition to sending the form to die address in 24a
Rotary
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: 1 construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,'Underground injection Control Program,
FOR WATER SUPPLY)WELLS ONLY: P 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) _5" Method of test: / 24c.For Water Sunniv&Iniection Wells: In addition to sending the£one to
the address(cs) above, also submit one copy of this forth within 30 days of
13b.Disinfection type: Amount: b�/� completion of well construction o the county health department of the county
where constructed.
Form GW-t North Carolina Department of Environmental Quality-Division of 1Vnter Resources Revised 2-22-2016