GW1-2021-03054_Well Construction - GW1_20210624

��ilt Form .
WELL CONSTRICTION RECORD( W-1) For lntemal Use Only
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I.Well Contractor Information:
Ronald G. Cannadv 14.WATER ZMES
well Contractor Name FROM I To D p1Prl N
n j.2z IL 8.
2�2�"t"1 using IJntt
NC Weil Contractor Ccnilication Nambct ►nIcTm3tion pC�� ft• R,
.VR SedOn 15.Ot3T13RCAStNG faros Wdh 1}RLINER' fa licable
Cannad Brothers Well D&ng, Inc. FROM TO DIAMETER TIIICI. ESS MATERIAL
Company Name R• /3 D' t` jp• yv L
16.INNERCASING ORTUBING tbst�tittlosed-too
2.Well Construction Permit 0: FROM TO DIAMETER TRICIt1sESS MATERIAL
LLst all applicable well constmedon permits N.c.111C Connor State,I'ariance,etc.) R• it, In.
3.Well Use(check well use): R• rt, In.
I
cr pply Well: 17.SCREEN
r FROM TO Drnnt R r .. nucan arAreatAL
ricuhurnl �Mtmicipal/�'ublic0 3D rt, �+p q, t In. ,0a,othermal(Heating/Cooling Supply) Residential Water Supply(single) in.ustrial,tCommercial [3Residentiai Water Supply(shared) 18.GRO tion FROM To A TERtAL Bet CE fFATM I D& totirrr
WaterSupplyWell: © R .2L) D• /V� P pa"nitoring Recovery (L R,
tion Welt: — y"uifer Rtcharge oGtotmdwatcr Renrediatioa19.SANDlCRAVEL PACK f licwbleulferStorageandRecovery Salinity Sorrier FROM To MATERIAL UI LACOIEnzMEMOD
uifer Test DSlotmwatcr Drainage eperimental Technology Subsidence Controlothrnnal(Closed Loop) DTM=r 20.DRILLIN(t LUG`attieh Additional sheets
othermal Heatin Conlin Return) Other(explainunder#21 Remarks FROM TO DFSCRIYi7 o N cobr,Aardoesr.snittrarit todmem
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4,Date Wells)Completed:' 6 J Well IN j n• j n• 81
�r-t,�f
So.Well Location:
-,E��°�t..t'.w(rG�I�M•.fL �: �„j�F/�u'h'v►`/w' (� 8. $" rt.
Facility/O ncr NaMe d'c'a .
t,(,, ,,y ( / Facility ID#(if applicabic) n A. /90% a.A- 11 V4-d Physical Addrcsq,City,and Zip �,c f y y R It.
21.REMARKS
County Parcel Identification No.(PIN)
Sb.Latitude and longitude in degrea0minutestseconds or decimal degrees:
(if well field,one 1:10long is sufficient) 22.Certification:
6.Is(are)the well(s)GI04onent or OTemporary Signature of Certified Weil Contractor "" u
By signtag this form,1 hereby crnt&that the nett(s)xvs(weer)consmucted in arcordance
7.Is this n repair to an existing well: OYes or [:)No Wth 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Corurrocdon Standards and that a
(f ibis is a+rpalr,Jill oat knoune nett consmrctfon lgfornatlon and esplafn the nantre ojd+e co ofthis record has been prodded to the well auvw
mixdr trader 621 rrnrariU section or on(fee hack gfthisjorm, 23.Site diagram or additional well details:
8.For Geoprobc/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page 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 INSTRUCTIONS
9,Total well depth below land surface: 1 (R•) 24a, For All Wells: Submit!this form within 30 days of completion of well
blernntldple wr/dr list all depths fdigerent(eminple-3 n 2M'and 2(n1111ir) construction to the following:
10.Static tenter level helots top of casing: Division of Water Resources,`Information Processing Unit,
if over Inv/is abatr casing,ase '+ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: -r (in.) 24b.For Illiggio Wells: In'addition to sending the form to the address in 24a
Rota above,also submit one copy of this form within 30 days of completion of welt
12.Well construction method: Rotary construction to the following:
(i.e.Hager,rotary,CAIttC,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) y Method of test: I2 24c.Fnr Water Spnnly&Wiectioo Wells, In addition to sending the form to
z the address(cs) above, also submit one copy of this form within 30 days of
13b.Disinfection type �s-s.Qa1.t, Amount completion of well construction to the county health department of the county
where consweted.
Form e3W-I North Carolina Department of Environmental Quality•Division of Water Resources Revised 2-12-2016