GW1-2021-05549_Well Construction - GW1_20211013

WELL C0NR8J1GTJQNFor(ntetria Use Only:
1.Well Contractor Information:
Ronald G. Dannady Vroa essln( 14., A BR ES
FR Well Contractor Nome �ftfiOiC [)TRSOIC�1— Alln n TO p � 0�'
2126-A
NC Well Contractor Certification Number 119 OUTER CASING Ituratuld4aW wells)OR LINER A ble
Dannady Brothers Well D(llingr inc. FROM TO DIA iL7_ THICKNESS '"ATtR1AL
b n ,1 �n. 10- �,fd JCJ
Company Name
O d d /u t :INNERTUBINGih cued-I
2.Well Consiruction Permit 0: W G 1 / 7 P FROM met —WAL
Ust all appiicable"I/construction permits fl.e.111C Gnarly.Rate.Parlance,etc.) A. ft. In
3.Well Use(check well use): 17.SC O'EN
n (�
Water Supply Well: Oat
Agricultural 0MunicipalOublic �I. n. In. r 6�� p G �t
3
,Geothermal(Heating/Cooling Supply) K antial Water Supply(single) n• n In
lndustriaVCommcrcial E)Residcntial Water Supply(shared) Ill.GROUT.,
Irrigation RI. , F t c O NT
.
Non-Water Supply Well: n. n. 64
Monitotin Recovery ft. rt.
Injection Well: n• ft.
Aquifer Recharge 00roundwa►er Remediation
l Q 'V81.PA f
Aquifer Storage and Recovery Salinity harrier at TO MATERIAL LAC a h TROD
Aquifer Test E)StormwalerDrainage 0 . A. �? A. t� i� /
Experimental Technology C)Subsidence Control ft. n•
Geothermal(Closed Loop) 0Traccr 20.DRILLI 10 LWO i ;I— . 1
,Geothermal Hetalin Coolin Return 0ihcr lain under N21 Remarks FR O D 11FT10 rears ueet a ar.
v
4.Date Well(s)Completed: n,5: I Well ID# 3 S n• 3 n' r` I;q
n. n.
So.Well Location:
Facility/OwncrName NJ CFacility lDN(Ifipplicnblc) R n,
C n. n.
Physical.Address,City,and Zip n' M
77777
REMARKS
County Parcel Identification No.(PiN)
Sb.Latitude and longitude in degrees/minoteeseeonds or decimal degrees:
(if well netd,one Is0long is sumcient) 2L Certification:
31s° . b 3 N -7&'• qs 09&-3 W
F
6.is(are)the wells) ermanent or Temporary SignaturcofCcrtifiod Well Contractor > Date
k.signhig lhls form.I hereby carttfy that the ue11(s)»vs More)constrtcled in accordance
7.Is this a repair to an existing well: 93d or [3No with 15A NC'AC 02C.0100 or 13A NCAC 02C.0200 tole//Construction Standards and that a
I/this is a repair,Jill out Immrir troll construction information and explain the nature of the , copy 4f this record has begeir prowded to the imil miner.
repair under 021 remark,section or on the back grthls farm.
, 23.Site diagram or additional well detslls:
8,For Gcoprobe/DPT or Closed-Loop Geothermal Wells having the some You may use the back of this page to provide additional well site details or well
construction,only I GW-I is needed, Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SjOMILEAL IM1tU>f'TtOi A
9.Total well depth below land surface: � r (R•) 24a. For All WIN Submit this form within 30 days of completion of well
1br mrdtiple uvils list all dcptlAt tf d(Q'erent(i:raniple-3Q20n dad 205I till•) construction to the following:
10.Stndc water level below top of casing: (R•) Division of Water Resources,Information Processing Unit,
ff wirer liner is abmr casing,use"r"t( 1617 Mall Service;Center,Raleigh,NC 27699-1617
11.Borehole diameter: r (in.) 24b,Far tolotion 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 well
12.Well construction method: Rotary construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Rawurces;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Servke'Center,Raleigh,NC 27699-1636
i
13a.Yield(gpm) 1 Method of test:—dil 24G For Wwr AggaEy& ►oiectian Wells: In addition to sending the form to
o� n ,. the address(cs) above, also submit one copy of this form within 30 days of
13b.Disinfection type:S—r--^"'�" Amount.7•p D 2 P completion of well constructions to the county health department of the county
( where constructed.
4
Fount OW-1 North Carolina Depoilmani of Environmental Quality•Division of Water Resources Revised 2-32.2016