GW1-2021-04430_Well Construction - GW1_20210811

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'VV-l1 For Internal Use Only,
1.Well Contractor inrarmaHon:
Rgnald G. Cannad t
Well Contractor Name �R R, I .t•
2126-A R.
NC WellCotnmctorCcrlillcationNumba l8 t) C G attic 9 L Rlt a ble
Canna Brothers Wall Drilling, Inc. ^t �° °) t n ' '
n. rt. 11 trt d 0 L
Company Name 0
2.Well Construction Permlt a:.�C,l G a a d f0 Fa°t a E
List all applicable trelf eonrtnrcflon permtfs(l.e.1/1�C.CoaNy.SYale.lizriance.etc.l
R• tn.
3.Well Use(check well use): R.
Water Supply Well: vsoMJ Tn
I DIAMncat�
Agricultural ®Mantel' ublic R, FOR.
71 V J
0collicnal(Heatinyf Cooling Supply) idential Water Supply(single) R• tt. in .
IndustriallCommerciai OResidential Water Supply(shared) GROUT,
Irti atitm o
Non-Water Supply Well A. fi. p.'
MonitoringRccov R. rt.
n ection Well: 1t. n.
Aquifer Recharge 00roundwaler Remediation
l9 i,PACK tit
Aquifer Storage and Recovery DSalinily Bonier FROM IG MA IAt. F A M6PtYVMOD
Aquifer Test OStormwater Drainage SCJ ft• 0 d R` /p
Bxperimcntal Technology OSubsidenee Control R• R•
Geothermal(Closed loop) DTmccr L
+RO O wdltnuk stt�erd:
Geothermal Head Catlin Return . Other lain under 021 Remarks
i=
4.Date Well(s)Completed: Wen 100
So.Well Location: '!
1 ", era R.
Facility/Owner Name vU Facility tbp(irapplicabte) rt Q-p R'
ZVI
Physical Ad reas.��City,find Zip P 0. 11�e1 et .5 t 0 �3 tlL R` rr.
9 9 ej i L- at.Rent KS
County Panel identification No.(PIN)
lip
u 4b.Latitude and longitude in degreWminutes/seceiRds or decimal degrees:
Iirwell Acid,ow latllong 6 suMclem) 22.Certification:
signature
6.ls(are)the well(:) rmattent or Temporary
Wellcontracia
�'sWing this fort,I hereby cert(6-that the nrfl(s)mu A—)cbtuftucftd4it at mrre
7.1s this a repair to an existing well: (ayes or. n9fh I JA NCAC 02C.0100 or!JA NCAC 02C.0200 Well Coosmrcll" dear a
i coin, this record has been Yded m the nail oidwnr.
phis is R frpalr,fill opt hnOttn n ell conttrkctton Irl jornratton a+td rzptaln the naan¢of flfe in,o
repair utter#21 rrrnarhs seetlat or on the hack ofth)s fame.
23.Site diagram or additionrl well details;
$ For CcoprobetDPT or Gtosed•Lor►p Geothermal Welts having the some You may use the back of this page to provide addition"til pAei}silt or well
construction,only I OW-1 is needed, indicate TOTAL NUMBER of wells construction details. You may also attach additional pages it
drilled: SLMMM�(,�� gj 1ot�s
a
9.Total well depth below land surface: � �,,, tB•) 24a, Far A�Wells: Submit this form within 30 days of of well
For rmdrlple arils list all depths(f if eraat lerampie•J@24n1 oral 2@10r) ConStnrotion to the fal)awing:
10.Stade water level below top of casing: a 5 (n•) Division of Water Resources,information Procel tg
B (/+later lewl is abmn cashrg,use 11, 3/ 1617 Mail Service Center,Raleigh.NC 27 1611 `
11.Borehole diameter:•„ s„/_(in.) Ub.Por in[rctton Walls: In addition to sending the farm co it udcksas in 24a
Rita above,also submit one copy,or this form within 30 days of completion of well
12.Well cotwlrnetion method: ry construction to the following:
(Le,auger.rotary"cable,dircel push,Cie.)
Dtvfalon of-Water Resources.Underground 1�E artr+at Pr "dm,
ROR WATER SilNl'LY''Wll ELLS ONLY: 1636 Mail Service Center,l;aidghi+tC 37fi9-lt,3t
13n.Yleid(gpm) v Method of test: �� 24c.ERE Will flog y.jf( ( on iVells: In addition to sending the form to
the address(es) above, also 'submit one copy,of this'farm +vithin;,30 days of
13b.Disinfection type: y ?—Amount: AV A7 completion of well constructicm to the county health dgwITTImit of the county
tuber a constructed:
Revised 2.22.10t6
roan QW1 North Carolina Department or Environmevits)Quality•Division orwater Rcs�ourcoa
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