GW1-2021-04305_Well Construction - GW1_20210430

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WELL CONSTRUCTION RECORD tCW-D For internal Use On y:
1.Well Contractor Information:
Ronald G. Cannady 14.WATERZONES
FROM TO DESCRIPTION
Well Contractor Notttc „� n. R• 61J8-�a it a'
2126-A
NC Well Contractor Certification Number tS.OUTER CASING for multi-cased dv h OR LINER if a llcebte
Cannady Brothers Well Drilling, inc. FROM � TO n. DIAMETER
1n THICKNESS MA vl(L
� y�
Company Name 16.INNER CASING OR TUBING thcrnml:closedduo '
2.Well Construction Permit#: - ao o d .1 � FROM TO DIAMETER TH CKN MATERIAL
List all applicable+rclf construction permits(i.e.UIC.County,State.I ariance,etc.) n R• In
3.Well Use(check well use): n. n. in.
7.SCREEN
Water Supply Well: FROM ro DIAMETER I I HNFSS MATERIAL
Agricultural B�2idcilntial
PaUE'ublic ft. fL In. v! "'"
Gcothermal(Heating/Cooling Supply) Water Supply(single)
IndustriaUCommercia) [3Residential Water supply(shared) III.GR0 T
iJ1i anion FROM TO tl 1 EM CE ENT M D&AMOUNT
Non-Water Supply Well:
Manitvring Recovery
Injection Well: n. n.
Aquifer Recharge Groundwater Remedintion 19.SANDIO dSL PACK ita... kabl¢
Aquifer Storage and Recovery Salinity Barrier FROM MATERIAL 6V1PLAC MEh-rMETHOD
Aquifer Test E)Stonnwater Drainage n' 5 R' ' 9'+-b uw�
Experimental Technology [3Subsidcncc Control n. n.
Geothermal(Closed Loop) 0Tm= 20.DRILLING LOG tatttit h addidoital stxaffi ncewsity)
FROM D.F,SCR PTftON toter,bards k t to elxr,ate.
Geothermal Hcalin Coolin Return Odxx(explain under#21 Remarks n, n,
4.Date Well(s)Completed:�—I Cf Well ID# h• fL
n 35 rt.
5a.Well Location: /L
Facility/Own" f• Facility IDu orapp eabtc)
OT n. it. � T..4 4.•r.
Physical Addros,City,and Zip
a &-3
/ O/ 7 9 -7 a 21.REMARKS2 to
�~County Parcel Identification No.(PIN) 7,3
5b.Latitude and longitude in do reeslminutes/seconds or decimal degrees: " "
g g eF, rii.,+ , �„ .
(if well field,one latilong is sufficient) D 2L Ce fication: v[ Ott
,_5aeig9 ► o N '� 3 ? SSW <0 j,ow
_ 6.Wore)the wells) ermanent or Temporary Signature of Certified well Conuactor,• Dote
sy signing this form,i hereby cent&Thar the ur!!(s)uvu(.+rml constructed in accordance
7.Is this it repair to an existing well: 1Yes or 0 with iSA NCAC 02C.0100 or 1.5A NCAC 02C.0200 IVell Consinucrimn Standaris and that a
If this is a repair,fill out knouvt null construction hifornmNon and explain the nature of the . copy of this record has been prmided to the null owvter.
repair under H21 reraarkv section or aru the back gr1his form. 23.Site diagram or additional well details:
8.For Geoprobe/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 1 GW-I is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: (R-) 24a. Fo All Wells: Submit this form within 30 days of completion of well
i or muhiple r,r/ls list all depths Ird18'erent("ample-3@,,200'Wild 2@1(mr) construction to the following:
10,Static water level below top of easing: , {ft.) Division of Water Resources,Information Processing Unit,
lfwater level is abom casing.live"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: '3 (in.) 24b.For Iniection Wells: in addition to sending the form to the address in 240
Rota above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: ry construction to the following:
(i.e.outer.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) �� aD Method of test: /& 24e.Fm Wa.tyr Stionly&lgjgedon 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: �.O p r t')V completion of well construction'to the county health department of the county-
where constructed.
Fort GW-i North Carolina Deportment of Environmental Quality-Division of Water Resources Revised 2.22.2016