GW1-2021-03367_Well Construction - GW1_20210603

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WELL CONSTRUCTION RECORD(GW-11 For Internal Use Only:
1.Well Contractor information:
Ronald G. Cannady 14.WATER ZONES
Well Contractor FROM TO DESCRIPTION
Name a, `2�R. �
2126-A
NC Well Contractor Certification Number i IS.OUTER CASING for rain cd irells OR 1:INER if a Iieable
Cannady Brothers Well Drilling, Inc. FROM TO DiAAiMR THICKNESS MATERIAL
R. d a. 9 i r In. ve vL
Company Name
Ib.INNERCASINGdRTU TUBING thcrtanfclo:cddoo
2.Well Construction Permit#: �> J D v 0,0 3 v FROM To DIAMETER TIHCirnFss MAT>auw
List all applicable urll eonsinredon perndls(i.e.U1C.Coanw,State.1 arlanee,eve) R. R. in.
3.Well Use(check well use): R. h. In.
17.Water Supply Well; FROM I To nixt—oETER—L st orsig TuICKNFU MATERIAL
Agricultural Muni"aU�'ttblic ft. A'avR- _ 7 t in. p\/6 L�
Geothermal(Healing/Cooling Supply) .Water Supply(single) R. R• In.
IndustriaUCommemial Residential Water Supply(shared) IL GROUT
Uri tloa_ [19.
ROM TO hi TERIAL EAIPLACEAIEIIT METHOD&AMOUNT
Non'Wnter Supply Neil: n' ft' L PdiJ�►
Monitoring Recovery h. R.
Injection Well: R, h.
Aquifer Recharge Groundwater Remediation
SANDIGRAVELPACK l' lcnblc
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL "I'LACEAi 'T AIETHOD
Aquifer Test C)Stonn\\TiterDrainage �R' /,ZC�R -to /�o "
Experimental Technology [3Subsidcncc Control h• h
Geothermal(Closed Loop) [31fracer 20.DRILLING LOG-to addiflonod sheets it
67tOM •TO I)MCIHPTTON color.b rdam.!MUrack"ve.grain sin.etc.
Geothermal Hcatin Coolin Return) 130thcr(explain under#21 Remarks) O
4.Date Well(s)Completed: ^�► 11 ID# 3 < h.
R D
Sn.Well Location:
_'• l �tavt�tkn'� 0 t)R J2 Of
Facility/Owner Name Facility IDit(ifopplicable) a• R'
Physical Address,City,and Zip
0 I S y�O U 1 21.REMARKS
County parcel Identification No.(PIN) r.r ram v
Sb.Latitude and longitude in degreeslminuteslsmrids or decimal degrees: y t
(if well field,one latilong is su&cicm) 22.Certification:
-�539 3
_ . ° Dow
6.Is(nre)thewell(%) ermanent or Temporay 8igmrc orCert'eed Well ,
4signing j abytr(6,tuat the ne//(s)uvs(urre)constrtcted in accordance
7.Is this a repair to an existing well: Epre-11—or QNo ufth 13.4 NCAC 02C.0100 or 15.4 NCdC 02C.0200 Irell Construction Standards and that a
IJ•thls is a repair,Jill oaf knovrn vvrl/consiniction liornation and emplain the nature of the e ropy of(his recoil has been provided to the null outer.
relmir under 021 remar#s sectinn or on the back of this form. 23.Site diagram or additional well details:
8.For Gcoprobc/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this pogo to provide additional well site details or well
construction,only I OW-1 is needed. indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL iNSMCTIONS
9.Total well depth below land surface: -(n•) 249. For All Wells: "`Submit this form within 30 days of completion of well
t•irr nwhiple urlls list all depths ifdiQerent(erarnple-3 On 00'and 2(aJl(M') _ construction to the following:
10.Static water level below top of casing: b t S (tt.) Division of Water Resources,information Processing Unit,
Ifi ater leml is ahoy cosing,tiro.,+.. 1617 MnU Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.) 24b.For Infection wells: in addition to sending the form to die address in 240
above,also submit one copy of this form within 30 days of completion of well
12.Well coastrnetion method: Rotary construction to the 1161towing:
(i.e.auger,rotary,cable,direct push,ctc.)
"Division of Water Resources,Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh.NC 27699-1636
139.Yield(gpm) j �z t Method of test: {7 � 24c.For Water Sunnly&Injection Wells: In addition to sending the form to
_ the addresa(is).above, also submit one copy of this farm within 30 days of
13b.Disinfection type: Amount: �r� completion of wcII construction to the cotinty health department of the county
where constructed. I
Fonts GW-i North Carolina Department of Environmental Quality-Division of Water Rwourc i Revised 2.22-2016
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