GW1-2021-07060_Well Construction - GW1_20211129

B�
i s .
WELL SON T UCTIOI�RELM giW-I I FOt Intemal use unly.
1.Well Contractor information:
Ronald G. Cannady14..WATERZONKS
Od1 TO 0ESC ON
Well Conimctor Notnc a R. V R.
2126-A lL
S NC Well Contractor Ce"ifletnionNumber 11 OUTER C faro W "`1 : OR Li1149R' s tRlrk
uannady Brothers Well Ddifing, Inc. moil � TO R• IANE7ER10. ICKN MA'MRIJ AL
o p s„Jcy u p uC
Company Nntnc 16.1 ER CASING OR TUBING I;eloWd
2.Well Construction Permit 0, W11 i� r?tL lS .y FROM DIAMETER I TRIMMA IAt
List all applicable troll cwtsinicttan pernihs li.e,VIC Cannip,State,Narlance,etc.) ft A. in.
3.Well Use(check well use): n. ft. In
Water Su pp Well: 17.SCREEN
pp RO A !T SizE flCIC MATERIAL
Agricultural
Mq ipaU)'It I �(�n. ft. I• in Z /°.+�
Geothermal(Heating/Cooling Supply) 13cesidential Water Supply(single) R, ft. In.
Industrial/Commercial E)Residential Water Supply(shared) 1&GRO
- hri lion FROM . TERI E 1 C EAT OD AMRVW
- -- -
Non-Water Supply Weil: () n, PO ft. a At
MOnitorin Recovery % ft.
necon e :
a. n.
Aquifer Recharge [30roundwaler Remediation I9 SAtRLQRAV9L PACK f: table
Aquifer Storage and Recovery Salinity Harrier FROM I TO MATERIAL I EMPLACEMENT METHOD
Aquifer Test OStormwater Drainage A t) ft' 7 v ft. y8 �'� /G k04-`
Experimental Technology [3Subsidenee Control
Geothernal(Closed Loop) 13Tmccr 20.DRILLING LOG ache dual:' 1f
Geothermal Reatin Coolin Return) Olht:r(explain under#21 Remarks FROM To D wrl N ealor,ugrd sotUttuk lit.
AWWw
4.Date Well(s)Completed: eel (o+2 641 IN Q' S ft PIAIU..
{ cqwov
a.Sa.Well Location: n S , n.
4 d ft. n.
FacililylOwncrName Facility iDN(ifapplicable) �s ft• �P n.
511Z) WAI FZPL w ate- y)C. Cv 0 ft. 70
physical Addrm%.City,and Zip '1'��14�tg L a• n• ° "t' i+r t`-' l
ad2i.REM
County Parcel hkoti(ication No.(FIN) ,
4b.Latitude and longitude in degreestminuleslucoods or decimal degrees:
(if well held,one laillong is su6teien) 22.Certification:
& _ Sig*uTrc of Ccttirwd—Yell Contractor
epot s(arr)tRewe11(s) � teaent—or_ 1mafy a t>atc
—
By srbming this Jinn,1 hereby ceriO that the tre/l(t)tms(I—)constructed is accordance
7,is this n repair to an crdit(nl(weq: Cs or 13No with 1SA NCAC fi2C.011JO or 15A NCAC 02C.02Q0(dell Construction Standards and that a
if this is a jTpair.Jill out LntaHA moll construction iti)onaation and explain Ike nature of the copy of this record has been provided to the nrll rntmr.
mpair ender B21 trtnarhs seeNmt or on the hack ofthtsfot»,. 23.Site diagram or additional well details:
f .
You may use the back of this page to provide additional well site details or well
8.For Ceoprobe/DPT or Closed-Loop Geothermal Wells having the same
construction,only I GW-i is needed. indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: S MiTT L INSTRUCTIO S
9,Total well depth bolow land surface:. (h) 24s. For All Wells: Submit this form within 30 days of completion of well
t For multiple uvils list all depths if djpbrnnt h tantpl¢•3 r@.200 and 2 to?Off construction to the following:
10.Stade water level below toil of Colin S: (R•) Division of Water RebonrCCS,information Processing Unit,
/fttwter leivi is about casing,ur¢ 1617 Mail Service Center,Raletgh,NC 27699.1617
, 1 s
11.Borehole diameter: (in.) 24b.Fgt iniWAK W@lis: in addition to scudding the form to the address in 240
above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: Rotary construction to the following:
(i.v,ougar,rotary,cable,direct push,etc.)
Divislon of Water Resources;Underground Nection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service,'Center,Rolelgh,NC 27699-1636
138.Yield(gpm)_„2_______..-_ Method of teat 24c.far Water SWtBty&Ini�on Wells: in addition to sending the farm to
IL
n
Inc addresg(es) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 2 6 6 &A6 completion of wcii construction ito the county ltcalth department of the county
where constructed. k
Revised 2-22-2016
Form OW-1 North Carolina Department of Environmental Quality•Division of water Rcsourcvs