GW1-2021-04567_Well Construction - GW1_20210429

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WELL CONSTRUCTION RECORD GW- ® For internal Us
1.Well Contrnctan4aAmuffition:
Ronald G. Cannad "��* •Q� 14.WAT.98 ZONES
Well Contractor Nome Gr'Q �, M TO DESCRIPTION
2126-A Ps 5j
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NC Well Contractor Certification Number �^�O�� 15.OUTER CASING for tnultl.dtsed wefts OR LINER f n IfeaDle .
Cannad E3rothers Well L�rWK, Inc. FROM TO DIAMETER THICKNESS MATERIAL
Y 1a 3 p R. y tJ
Company Name
�j �J 16.INNER CASING OR TUBING
ettth'' ftdoseddiiti '
2.Well Construction Permit II: hX.) / — l�r7 U`' 1 FROM TO I DIAMETER I THICKN I MATERIAL
List all applicable it-ell cwutmolon pernlo(i.e.111C Count),,State,I nrianee,etc.) R. 1W in. sow
3.Well Use(cheek well use):
R. R. in.
Wafer Supply Well: 17.SCREEN
pp y FROM TO LAM •t MESTit CKNESS MATERIAL
Agricultural �MtlnicipaUpttblic ft /t4to rt. ./'in:
Geothermal(Heating/Cooling Supply) ffKidetttial Water Supply(single) R. R In.
Industrial/Commercial Residential Water Supply(shared) IL GROUT
Irrigation FROM I TO I1 RRIAL EsI CEMENT MI:T1190&AAtOUNT
Non-Water Supply Well: © R. p ft. t vasl,,
Monitoring Rccovcry _ R. R.
Injection Well:
Aquifer Recharge OGroundwater Remediation
.SANDIGRAVELPACK if ri ticablc
Aquifer Storage and Recovery Salinity Barrier FROM TO MATERIAL I EN LACEMF.N'T METHOD
Aquifer Test ®IStormwater Drainage p!) h / D
Experimental Technology Subsidence Control
Geothermal(Closed Loop) [3Tmcer 20.DRILLING LOG IdHach oddid slxets'dfiiecessa'
Geothermal Healin Conlin Return) Other(explain under t121 Rcmarks FROM TO DESCRIPTION(cater,luud■M sall/mck rsM to sire,etc.
h 17 rt.
4.Date Well(s)Completed: 3 ^ 3/~ �)c1111N) / R• 3 h.
5a.Well Location: 3 IR rt Q fL lo:..i` (U
Facilitlit 1Ownc� FacilityIDII da licablc) R. R. )
Y A �(� PP t' G P�) /1<
3 �I ✓lam/' (T6.rJ[d vW , C' �i L/7 1 0 U R. R. Lj
Physical Address,City,and Zip j/ Sri'
21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well fieid,one lat/long is sul)'icien) '22.Certification:
6.Is(are)the wells) e-rmanent or OTemporary Signature of Certified Wcll Contractor 'r Date
By signing this form,1 hereby cenfy(hat the ttell(s)was(mare)eottatnicted in accordance
7.Is thisa-repair town existing-woU: DYes or o ttith 15A NCAC 02C.0100 or 15A/JCAC 02C.0200 Well Construction Standards and that a
f this is a repair,f ll ou(knomt erll construction 0)fonnation and explain the naaae of the rop)'of this record has been provided to the moll oarner.
repair under 021 remard's section or on the back of this fora. 23•Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loap Geothermal.Welts having the same You may use the back of this page to provide additional well.site details or well
construction,only I G\V-I is needed. Indicate TOTAL NUMBER ofwells construction details. You may also attach additional pages ifnecessary.
drilled: SUBMITTAL,INSTRUCTIONS
9.Total well depth below land surface: 1 J Z/ v/� t.) 24a. For All Wells: Submit this forth within 30 days of completion of well
For multiple mells list all depths if d(flerern(erample•J@201i'mrd 2 a 110) construction to the following:
10.Static water level below top of easing: � (ft.) Division of Water Resources,Information Processing Unit,
junter letrl is abate casing,use"+^' 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: J o _On.) 14b.For lniecdon 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
i.e Well construction tl, method: construction to the following:
(i.e,aubrer,rotary,cable,Jin•et push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: nn 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: &l C R- 24c.For Water SSunn -&lnpac ion Wells: in addition to sending the form to
C��fl the address(cs) above, also submit one copy of this forth-within 30 days of
13b.Disinfection type: Amount: �tJ completion of well construction to the county health department of the county
where constructed.
147Il
Foot GWl North Carolina Department of Emironmcmal Quality-Division of Water Resources Revised 2-22.2016