GW1-2021-06604_Well Construction - GW1_20211007

�Vim __CONSII8•t IJON MC-0RD QN-D Fot internal Use Only:
I.Well Contmetor Information:
Ronald G. Gannady
-14..WATERYZ
M rnow
Well Contractor Name R. R.
2126-A
NC Well Contractor Certification Number 13.OUTER CASING Ibis suit ' 1IN R a teabte
Cannady Brothers Well Drilling Inc. pit T� IA EnR CKN MATERIAL
s n rt. !' rn v�
CnmpanyNamc 1 /� l tbrt R 1 0 R BIN '
21 .0 a 3`' J D DI C t
2,Well Construction Permit R:
Ust all applicable null catsmiction permits f.e.VIC.County,State,t crlauce,etc.) rt ir. In.
3.Well Use(cheek well use): ft. R. in.
Water Supply Well: ri o H tt I hJATFRlAL
Agricultural �Munfei'ol/j'ubIic ) JG
PA
Geothermal(Hcat'ingiCooling Supply) bRgidlwial Water Supply(single)
Industrial/Commercial oResidentiol Water Supply(shared) IL GROUT.
Im' ation FROM I TO M IN VT
-- - Non-Water Supply Well: D, ) rt; — A _ _ Od
Monitorin Rccov A. rt.
Injection Well: ft. rt,
Aquifer Recharge E)Groundwalet Reme:diation
If 60cidAel
Aquifer Storage and Recovery OSalinity Barrier FROM D T AC MATERIAL DIE LACE ETHOD
Aquifer Text 0Stormwater Drainage Olt R' R• i /&P f�
Experimental Technology E3Subside nec Control
Ocothcrnlal(Closed Loop) OTmecr DRI tNt2 rttetc dI
Geothermal Hcatin Coolin Return Other ex lain under 021 Remarks D la su see.
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4.Dale Wells)Completed: ::-3 v�! Well ID//
So.Well Location: s R. V
n.
Faeilily/Owner Nome Facility IDN(if applicable)
A -3 7 y Al f-A WG ft'R. rt. i
Physical Address,City,and 7 ip �y y CI
1.REMARKS
• ^ n Unit
Coonly Parcel Identification No.(PIN) in
�.
Sb,Latitude and longitude in degrees/mMutcalseconds or decimal degrees: 1�Of cj8Cl10n
(ifwell field,one ladlong is sufficient) I I I22. Uteation:
wyo 9 2N -?,°, W o //' /(Q`
§iJwtumorCeni Wall Contractor I fmc
6.Is(are)the wells) manent or_01remporary
By signtag this form,I hereby cWJ6,that the nrll(s)arts 6rare)coturnteted in accordance
7.Is this a repair to as existing well: Oyes or Will I SA NCAC 02C.0100 or l5A NCAC 02C.0200 Well Consawlio t Standards and that a
If this is a repair,fill out knom lull construction ittfbnnorlon and a*aln the nature of the copy Qf rhls record has been proildeed to the urR ouwm.
repair wider 02l remarks section or on the hock gfthis form, 23.Site diagram or additional well details:
8,For Geoprobe/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: MIi'fAL 1P1STR1,Q ONS
9.Total well depth below land surface: (n•) 24a. For All Wells: Submit this form within 30 days of completion of well
1-ar nudtlple nrlJc list all depths Ud(farodt(eromple•3Q200'and 2(?I fHn construction to the following:
10.StaHc water level below top of casing: s (ft.) Division of Water Resources,Information Processing Unit,
(f uprer leivi Is abotr casitrg,use"+" 1617 Mau Service Center,Raleigh,NC 27699.1617
It.Borehole dinmeter: t (in.) 24b.For Infection Wells: in addition to sending the form to the address in 24a
Rotary/ above,also submit one copy of this farm within 30 days of completion of well
raM 12.Well constion methods 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 Mall Servtc�Center,Raleigh,NC 276"-1636
13a.Yield(gpm) y �/ Method of test: 1� 24c•Ear Witu fingilh&Inleftn Wellst In addition to sending the form to
/� the address(e:s) above, also submit one copy of this farm within 30 days of
13b.DlslnfeMion type: Amount: ��/v m completion of well construction'to the county health department of the county
where constntcted.
I
Form OW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 2.22.2016