GW1-2021-05284_Well Construction - GW1_20210601

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WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
I.Well Contractor Information:
F>,
Ronald G. Cannady � I4.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Nome
2126-A 30N X 1 2021 ft• Ss R.
NC\Veil Contractor Ccaification Numbcr Cesog
R.
[0 t5.OtITER CASING fat mn)t(-canal mils OR LINER ifs tcnbte
Cannady Brothers 1 t1 �;°ihic. FROM TO DIAMETER THtclav MATERIAL
ft. 5 R. ,I in. JC.
Company Name
I&INNER CASING OR TUBING therront closeddoo
2.Well Construction Permit 0: WC d(-000NaLF FROM TO DIAMETER THICKNESS MATERIAL
List all applicuble urtl construtction pervtfts li.e.111C.Caaaq'.State.!crlance,eta) It. " in.
3.Well Use(check well use): fL R. in.
Water Supply Well: 17.SCREEN
PP Y FROM TO DIAMETER St OT SIZE Ti11CKNESS MATF.RIAI.
Agricultural r1��,dentisl
Utublic S R. R. J D in. O �Z y P� lam/Ys'
Geothermal(Heating/Cooling Supply) Water Supply(single) R, R, In.
Industrial/Commercial Residential Water Supply(shared) 1B.GROUT
irri ration FROM TO MATERIAL EMPLACEMEN'S METHOD&AMOUNT
Non-Water Supply Well: b "' R' 3 S C).
Monitoring 1311ccovery
Injection Well:
Aquifer Recharge Groundwater Remediation
19.SAND1G1tAVEI:PACK t lenblc
Aquifer Storage and Recovery OSalinity Barrier FROM TO I MATERIAL EMP c Ei1T METHOD
Aquifer Test OStormwater Drainage p?() "• 5 5 "' Vr}0 1 /�o
Experimental Technology [3Subsidcncc Control IL A.
Geothermal(Closed hoop) 13Tmacr 20.DRILLING LOG Isttieh additional sheets if lilceisa
FROM TO DESCRIPTION calor,hudatss.sorUtaek to she,etc.
Geothermal Hcalin tCootin Return) Other(cx lain under N21 Remarks)
4.Date Well(s)Completed: a i Well 11w (7"' U "'
5n.Well Locution:
a:
414/
fL -s R.
aility/owneflame, Facility IDN(if applicable) R•
14174o re C/u41 d 69L4;� I
A�' R. R.
Physical Address,City,and Zip & ff R. R.
21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degreesiminutes/seconds or decimal degrees:
(if well field.one Inviong is sufficient) 22.Certification:
6.Is(nre)the well(s) rmanent or Temporary SignatumofCeniftcdWcllConimcfor IF Dalc
4 signing this fonn.I herb,cert(6•that the'nellls)umms(urre)coUstnrcled Its accordance
7.Is this a repair to an existing well: or 0No ivith 15.4 NCAC 02C.0100 or/SA NCAC 01C.0100 Irell Constracdon Standards and that a
Irtlds is a repair,fill out kaoum null construction itt/onnation and ecplain the nature of the copy of this record has been prmided to the aril mrsuer.
repah•under 021 reutarks sectiart or on the back afthis farm. 23.Site diagram or additional well details:
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-1 is needed. indicate TOTAL NUMBER of wells construction details. You may also auoch additional pages if necessary.
drilled: SUBMITTAL tNiSTRUCTiQN5
9.Total well depth below land surface: '(11.) 24a. For All Wells: Submit lhis form within 30 days of completion of well
l'or nudliple rills list all depths if d�erent(awniple-3 n»Ml'and 2G 10ir► construction to the following:
10.Static water level below top of easing: (n•) Division of Water Resources,Information Processing Unit,
lfmmtyr/grad is above casing.use +"3�,! 1617 Mail Service Centex,Raleigh,NC 21699-1617
11.Borehole diameter: ✓ i (in.) 24b.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
f 2.Well construction method: 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 Mail Service Center,Raleigh.NC 27699-1636
13a.Yield(gpm) ! Method of test:_ ( �Z _ 24c.For Wnter Sunnly&Injection 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: -bb 9)pr7 completion of well construction ito the county health department of the county
where constructed. i
u
Foram GW.t North Carolina Department of Environmental Quality-Division of Watcr Resources Revised 2.22.2016