GW1-2021-06420_Well Construction - GW1_20210915

WEUL CONSTRtJCTIQN RECORD,jCW.11 For Interne Use Only:
Contractor Information:
Ronald G. Qannady
Wcl1 Contractor Nome FROM TO N '
2126-A 3 s n w
R. n.
NC Weli Contractor Cenitkntion Number �n M O C INC Por it d O L N u Idtbk
Cannady Brothers Well Dril ingr Inc. M TO DI S R1 THICKN MATERIAL
Company Name
Q R. 30 n. Zr In. y QU(a
I&I G I>s! ' l
2.Well Construction Permit k:�YYS i¢1 L -DD�j j3 pROM ro n1 t t IAL
List all applicable nvil construction permits ll.e.U1C,Cmmo-,Slate,I arlance,era) R. n. in.
3.Well Use(check well Ilse): R• n. In.
Water Supply Well: 11. PEN
`•�„• ,, O 1 A 11 fATrin1A6 r.n
Agricultural �Mu tpaU�'ublic © n. a n, r• In: O 12 � ( 12 OL ,.'I"'�
Geothermal(Heating/Cooling Supply) esidentiol Water Supply(single) R. R. In:
IndustriaUCommercial ®IResidential Water Supply(shared) I CR
hii lion o t c t D&n o
Non-tVnter Supply Well: � n. tt. � //b VI
;)Monitotins DR.0covery
Injection well: _ — ---
Aquifer Recharge - bOroundwater Remediation 19.SANOIGRAV19111sAC t k
Aquifer Storage and Recovery 13Salinity Barrier FROM I TO MATERNIAaL EMPLACEM IETHOD
Aquifer Test E)Stormweter Drainage A0 n- 85 n- J f4„` PdLLA-
Experimental Technology Subsidence Control n. • n.
Geothermal(Closed Loop) 0Tmccr rRILI.AO azure
Geothcrinal Houtin Coolin Return Other(explain under 021 RemarksT n a6rd turk 4.Date Well(s)Completed: a Well ID# . n. W go.Well Location: 3 R•
R. R.
Facility/Owner Name — Facility lDN(if applicable) n. n.
/9b a. '�� R. R s�
Physical Address,City,and Zip
s � 21,REMARKS
County Parccl Identification No.(PIN) .v r; nr n 1Pt U -
3b.Latitude and longitude in degrees/minntes/secoruls or decimal degrees: 6VVR SOSi'On
lKwell field,one IRUlong is suMcieni) 2L Certification:
3 y 0.$S6%(09 N -7$° 3 3 �S W --Pn-)UL � � i f 2,021
rmanent or era ra sismiumorCenifmd Well Contrwor' Date
6,Is(are)the wetl(s) [�T' po ry
���/ Op signing this jortn,I hersb,Cerro,that the urills)uas f%mm)constructed In accordance
7.Is this a repair to an existing went DYes or E)N WA I!A NCAC 02C.0100 or I S_A_NCAC 02C.0200 1Vell Consmxlkxt standards aad_that_o__
_ �.__ILrhls is rt trpair-fill out knotsn tFrl/rwurruerbn fr)(onnallon arrd etpla!»rhe`ndiure of7ic` py ! ti the imll onmr.
zo rhls rrcoid has bra iMdad i
relxtir under H21 retuorks section or on the back rorhls jami. 23•Site diagram or additional well details:
S,For Geoprobe/DPT or Clout-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 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary•
drilled: 2 SIBMITTQ1t,Rr{iSTRUCTIOiVS
9.Total well depth below land surface: `"�5 Aft-) ?As.For All Welts: Submit this form within 30 days of completion of well
hbr rnuhlple ur1Ls list all depths Ijdifferanr(avample-3@200Y alai glom construction to the following:
10.Static water level below top of casing: it (ft.) Division of Witter Resources,Information Processing Unit.
(/natar Ie,cl is abate MOW sae"y 1617 Mail Servlc iCenter,Raleigh.NC 27699.1617
11.Borehole diameter: (in.) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction method: Rotary above,also submit one copy of''this form within 30 clays of completion of well
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: 1636 Mail Service°Center,Raleigh.NC 276994636
139,Yield(gpm) U Method of test: 141& 24c.FfIr Wawr Suite&Inl on Weirs: 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: Od /�/gym completion of well cons►ructionI to the county health department of the county
where constructed.
Form OW-1 North Carolina Department of Environmental Quality•Division of water Resources Revised 2-22.2016