GW1-2021-05775_Well Construction - GW1_20211015

MLL f'UN$TIB,UCT1QN RECM_(CW-1 For lntcrna Use Only:
1.Well Contractor Information:
Ronald G. Cannady, �,� :y *��� MOUTIE&RCAMSING WATER
FROM DESC Ottl
Well Contractor Namet i y� R•2126�t1"1R.NC\Nell Contractor CcriiM alion Number �'-''' c:'' SINC for rant .*cI 3 bR~ O D1AhSBTER ICTiNESS MATERIAL
Cannady Brothers Well Q�lffh` I'ric s R. �� 5" w b
Company Nome C 2,Well Construction Permit 4. G `(XJ T DI tM List all applicable nr11 construction perrrths(i.e,01C.CnnnO',State,I ariance,etc.) � `r-, 1,
3.Well Use(check Weil use): R R. In.
17.SCREEN
1 atcr Supply Well: FROM TO I VIAMFTER1 1 N68 ,ATIialAL
Agricultural �Mun'1jial/ U`blic &35 ft. d t1. I In. p 2 �� 11s !
Ocothcsmal(Heating/Cooling Supply) esidcntial Water Supply(single) R, R. In.
IndustrioUCommercial DResidentinl Water Supply(shared) I&GROUT.
Irrigation IDRJRLL
I f nT M1t. O R A KT
Non--lYatcr Supply Well:
n• d.Ak rp7Mn
Monitorin Rcrov A. R.
Injection Well: - --- ----
Aquifer Recharge (30roundwater Remediotion
A AC !a ' `
Aquifer Storage and Recovery 13Satinity Harrier TO MATERIAL EMPLACE 1F�tT METHOD
AquifcrTesl DStormwaterDrainagc R. a/� / Pp7�,
Experimental Technology [3Subsidencc Control R,
Geothermal(Closed Loop) 13Trtcer C d td 11 ,Geothermal Hcatin Coolin Retum Othcr cx lninunder021 Remarks Dr_ Irrt akr o R.4.Date Welts)Completed: )'� Well ID# / 7 R• M
317q.l-2 bb pI /r-&, 'SnWell Location: - 1J,_a & V R.
Facility/OwnerNamc Facility lDN(if opplicabic) h. R.
52 fi 4wwattk1 � Y�- � N G• ft. ft.
Physical Address,City,and Zip R. R.
Grp 7 D S�S 6a,c 2 !� y 21.RSMhRKB
Cuunly Parcel Identification No.(PIN)
5b.Latitude and longitude In degretWminuteslseconds or decimal degrees:
of well Acid,one 1m)long is sumcleni) .22.Certification:
'oS.a� �a',/9,Z/A) W Rm aa �'� /6-1�- ,1d 2-
6.1s(are)the well(s) ermanenl or �femporary signaturcofeettifted well Contactor-� Date
Sig"Ing this oral,I hereby CVrlj6,rhos the 11e11(s)nus 61vre)constructed In accordance
— --7;Is this a-repair to an existing well:—nYes _or_ o_. _ Wih I SA NCAC 02C.0100 or I SA NCAC 02C.0200 Irell Constntcrtou Standards and that a
— c o ibis mcor1 has'been rortded-ro
1f Urls is a urpair,Jill our Jtnotrn tsrll construction Ig)brrnorlon and splahr the ratan ojrJre oPt' j —� —� "the keli-oaner':_
repair under N21 munnU section or on the back grthis 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 GW-1 is needed, Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: ��ItVSTRUCTIONS
9.Total well depth below land surface: (n•) 24a. For Ail Wellt: Submit this form within 30 days of completion of well
Far mrthiple hells fist all depths If different(sample-3@2170'ri4d 2@100') construction to the following:
10.Static water level below top of casing. I S (ft.) Division of Water Resources.information Processing Unit.
ff%%wer lctel is above casltrg,use"+" 1617 Mail Strvl*e Center,Raleigh.NC 27699-1617
/r
11.Borehole diameter: I° (in.) 34b.For Injection Wells: In addition to sending the form to the address in 24a
Rotary above,also submit one copy of this form within 30 days of completion of well
l2.Well construction method: ' construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources;Underground Injection Co tTol Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Ser'vicetenter,Raleigh.NC 27699 636
13a.Yield(gpm) Method of test: 24c.For atcC Snpaly A In(� Welts: In addition to i ending the form to
the address(es) above, also submit one copy of this form within 30 days of
�13b.Disinfection type. '+I Amount: O d completion of well construction'to the county health department of the county
y where constructed.
I
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Form OW-1 North Carolina Department of Environmental Quality-Division of water Resources Revised 2-22-I016