GW1-2021-06167_Well Construction - GW1_20211025

;prirat�Foi;rtii`•`
WELL C0P 8UjJ T1QTJ R&CORD(CA-1) For Internal Use Only:
1.Well Contractor Information:
Ronald G. Gannady
,e WATER a
Well Contractor Nance FROM I TO PICK IUMON
►t o n. / %Q rt, a
2126-A1.3D
NC Well Contractor Certification Number 15.OUTER CASING Ifor rgul O LINER fa etlbte
Cannady Brothers Well DrlU n , Inc._ Fa5m I To MATERIAL
y p �uG
Company Name
1 :INNER AS] t3 A N
2.Well Construction Permit N: FROM TO I DIAMMIL I THICKAMMATERIAL
List all applicable rrelf construction pernrhs(I.e.01C.Cnwrr)t Slate.Variance,etc.) n. R. la.
3.Well Use(check well use):
SCREEN
Wa SuPP y Well: 17.
FROM IA 11 KN tAT6RIAL
Agriculture) 0MunicipaU�'ublic t s R. Zen• la. Q y fw4A,1,,
Geothermal(Heating/Cooling Supply) optesidential Water Supply(single) D It. 5 D It.
la,! v
IndustritiXommercial E)Residentie)Water Supply(shared) 1
1rri lion FROM I To I`h EMPk A
Non-Water Supply_Wr-11: — -- -�' E�-0'- ti.P�t -— zn —
Monitorin CIRccovery
Injection Well: n, d. .
Aquifer Recharge C)Groundwaler Remediation
1 PACK(Ifitaptichblell
Aquifer Storage and Recovery C)Salihity Barrier MOs1 I TO MATERIAL EMPt•AC6(• METHOD
Aquifer Test OStormwater Drainage pv n• /s U R• ) o ►l prVA
Experimental Technology Subsidence Control n. R.
Geothermal(Closed Loop) (racer 20.DRILL 'abeft
Geothermal(1-1catinig ing Rcwm Other(explain under H21 Remarks FROM rsctl r ratline ne..
R. 100 R �w'J✓r.. Is a Ps e t
4.Date Well(s)Completed: 6 O"�� Well ID# 6 J R' d R'
5a.Well Location:
n. 8 V
Faetlity/Ownct Name fVX f(yHff-t Facility IDH(if upplicabic) p R• /0 2 n• �L bti/
/� 2 �• �. /IJ
Physical Address,City,and Zip 120 It.
21.REMARKS '
County Parcel 1daMincalion No.(PIN)
Q�ggl(t
Sb.Latitude and longitude in degreeslminutcafsecands e or decimal degrees: t,
(if wall field,one►al/long is sumcicnt) E2.Certification:
set ,o l zy y2N' 7�e �s . �� W
— --
- g- ann.I lierc ecru that * Date
6.ls(nee)the well(s) ermnnent or O'remporary
Si nature of ccoinod well Contractor
—7fp Igr rig j by (/j• h017he iirr(f(i)nt7i7wreh2)zattstnrered7n accordance — —
7,is this a repair to an existing wen: E;;e"so�®r J3N9 Milt 15A NCAC 02C.0100 or lJA NCAC 02C.0200 Well Construction Standards and that a
Ijthis Is a repair,p11 out known nr11 construction lt)/bnnarlon and eViela the notime ojthe eaM,ojthls rrcord has been provided to the ur11 owner.
repair andw 021 nentarkr section or on the hack gfthis jornt. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Clawed-Loop Geotbermal 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: g ► 1TT-�s�J�( jiUCTIGNS
9.Total well depth below land surface: D (R•) 24s. For All Wells: Submit this form within 30 days of completion of well
For nett ple nvik 101 all depths(fd1 feront(aromple•3Q2M1'and 2@110) construction to the following:
10.Static water level below top of casing: 5 (R•) Division of Water Resources,Information Processing Unit,
(jwarer!slut is above casing,ore"+" 1617 Mail Service Center,Raleigh,NC 276"-1617
1.Borehole diameter: (Ia•) 24b.For Infection Wells: In addition to sending the form to the address in 24a
12.Well construction mMbod: Rotary above,also submit one copy of This form within 30 days of completion of well
construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Divbion of Water Resources;Underground injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Serviceicenter,Raleigh,NC 276".1636
13a.Yield(gpm) 5-5 t' / Method of test: I— 24e.FnS.�E1StoltEY&1nleCaon Wells: In addition to sending the form to
the address(cs) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: aZ�a GPM completion of well construction to the county health department of the county
where constructed. I
Form OW.I North Carolina Departtnent of Environmental Quality-Division of Watcr Resour I" Revised 2.22.2016
e