GW1-2021-03751_Well Construction - GW1_20210823

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1.Well Contractor information:
Ronald G. Cannady_ 1VATRIA,
FROM I O P ION
Weil Contractor Nome R.
2126-A
NC Well Commetor Codification Nuttilm O R C G for m t WV13R' table
Cannady brothers Well DrUn Inc._ OA1 T DIAAtBTEN ICKN MAtRtt1A4
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Company Name
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2.Well Construction Permit 6: y? 3 Y y rao TO I DIAMEM 17111cicNI= -LAWTHIAL
List oil applicable trell consinteuon perm►ts(l.e.VIC,Couaq•.Siate,i'arlarce etc) H• R• is
3.Weil Use(check well use): It R. in
Water Supply Well. NS-A
rc a AgriculturalGeothermal(Heating/Cooling Supply) m p" eaidtial Water Supply(single) ft•Industrial/Commercial Residential Water Supply(shared)0- w lion 1 C OUNon-Water Supply Weil !t. v f? . f��n ec on e : n,
Aquifer Recharge 00roundwatcr Itemediation 1V9 bk
Aquifer Storage and Recovery DSalinity Barrier FROM TO KAATE At I EM RENT METHOD
Aquifer Test OStonnwater Drainage 0 fi t• �(tv J l b �^
Experimental Technology OSubsidencc Contras) ti• n•
Geothermal(Closed loop) DTmcWr Jt DRILtING
Geothermal(Hou(ing/Cooling Return tither cx lain under tt21 Remarks Wo To
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4.Date Well(s)Completed: Well i00 h b.L t• U
9-
go.Well Location: Q i v
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Facility/OwncrNornee�/►� / Facility IDH(ifopplicabtc) n• tt. `,�,
Physical Address,City,and Zip s h' It. r"s.SSt
21.REM s
CountA Parcel identification No.(PIN)
tab.Latitude and longitude in degmWininuteslseconds or dedmai degrea:
fir wall field,oneldillong is suMclem) 2L Certiikatlan:
N w wqm 0a
6.is(are)the wetl(s) ermanent or �i empot ary Signa urc olCerti tod Well Contractor � Date
M.string this form,I her*,ccwy that the urtl(s)fins(evre)eominteted in aaoMance
f3A NCAC OIC.0200-Wit Contra--loti Standards and Thar a
7,is fir
If this is a repair.pit out knour well construction trilbrmation and eiplaht the nature of the copy g/rhls recotri has teen pmmlded ro'tha urii oxrnr.
repair under H21 renarhs section or on the bark glthisfurnt. 23.Site diagram or additional well detallo:
S.For Gcoprobc/DPT or Closed-Loop Geothermal Wells having the some You may use the back of this page to provide additional well site details or wail
construction,only 1 OW-1 is needed. Indicate TOTAL,NUMBER of wells construction details. You may also attach additional pages ifnecessary,
drilled: atIRM._ trlA>t tivcrRut-riots
9.Total well depth below land surface: �_.._..a.._.. N 24a. • Submit this form within 30 days of completion of well
For atthiple ur//.c ilsr all depiki If differonl lexampte•J@2M1'and 2(utl(t ) construction to the following:
10.Stalic water level below top of cooing: 1-5 (f►•) Division of Water Resoutsee%information Promising Unit,
161uter Eves is above casing,use +" 1617 Main Service Center,Raleigh,NC 276994617
11.Borehole diameter: .53N (in.) 24b.�inigftlk Wells: in addition to sending the form to the address in 24n
above,also submit one copy of this form within 30 days of completion of wail
12.Well construction metbods R®tary construction to the following: I(i.e.auger,rotary,cable,direct pwb,etc.)
Division of Water Resiourcm,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276WI636
13a.Yield(Spin) 0 Method of test:-.4 24c.Ear Water finnift&lnieeiiom Wells: In addition to sending the farm to
the addroas(cs) above, also submit Ione copy of this form within 30 days of
13b.Disinfection type, Araonnt: aa� PPM completion of well construction io the county health deparimcnt of the county
where eonattucted. s
Fonn OW-1r North Carolina Dcpa mem of Environmental Quality.Division of Watcr Rcaourcoa Revised 2.22.2016