GW1-2021-07754_Well Construction - GW1_20211116

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1.Well Contractor information:
Ronald G. Cannady
ON
Well Contractor Name 0,1 C
2126-A
tl. IL
NC Well ContractorCorliflcationNumber O alai iL RR' t trio
Cannad Brothers Well DdWng,, Inc. OM T r R M 7ERIAL
rG h. a to sd.y vc.
Cntnp:tny Namc 14 i 11
2.Weil Construetion Permit 0:we 21—oonocl!z 01
List all applicable tirll earstnuciton psmt is(i.e.111C.Cmo)0-.State,Parlance,etc.) as
3.Well Vve(check well use): it. FL in.
stet Supply Well: 17.SCREEN
y a 1 HeATnRtAL
Agricultural vcls�ld'=111
al/Public h. h. r ia. D�2 t7ltkotitcrmal(Wcat(nglCoa)ing SuPAIY) ial Water Supply(single) h. R. in. t7ri
Industr'ia(Commercial 01tesidential Water Supply(shared) t
ll.GRO
(rrination
",Water Supply Weil: R. j) n. D
�OIII on
ectlon Weil, n. rt.
Aquifer Recharge [30rousndwater Romediation LPA t
Aquifer Storage and Recovery DSollnity Barrier PROM TO MATMIAL C t3rt M o
Aquifer Test oStosmwater Dminage e?d n• () ft. tJu1.
Uperintontat Technology OSubsidence Control
Ocothermal(Closed Loop) OTracer
rqho—
Geothermal Ncot(n Coolin Return Other lain under N21 Rcma s A. u p a`
4.Date Well(s)Completed: , � Well IDN R• R•
So.Well Location- R. h
Facll ty/OwrtcrNnmac� u , Paility ►knble)
physical Address.City.and Zip
'r)f p A' 21.REMARKS NOV ! 9 mm
County Parcel Identification No.(PIN)
�� �cGliiJi�
5b.Latitude and longitude in degr•eesIminuteahecomis or"mat duress:
(irwell field,one latilong Is sufftlerq 22,CertHleaBon:
0.1a(are)the well(s) manent or OTemporury Sig turc otconifWN-Vall conlMoor natc
8y rigrttng this form,i hereb),m7(&that the mrfl(s)aas Ream)corumrued to accordance
7,Is this a repair to an e�dsting web: Yes of - ulth)$A NCAC OK'.0100 or(JA NCAC 02C.o2oo Well Constnrctlon Standards and that a
if fittr ISO re)rn►r,pit out known well construct,*,,lgJbrrnat(on and taplain the Harare of the roPY Qhhls rcrnrr!Itas Dcen pmwdarf"roihe a 11 _--
,rpatr under 021 rmrarks secttmr or on the hack gr1hls for at.
23.Site diagram or additional well details:
You may use the back or this page to provide additional well site detaiis or well
6.Fort;eoprobelDl'T or CFtttteii•L.aop Geothermal Weill having the st►mc
construction
construction,only 1 OW-1 is needed. Indicate TOTAL NUMBER of wells details. You may also attach additional pages if necessary.
drilled;
9,Total well depth below land surface: 7 �m.,,, (ff.) 24p. For'AH Wellst Submit this form within 30 days of completion of well
Firs mrdtiple%Wk lest nH depths(f rif amn►(nramp(�)Q10n•ad 2 r@1off) construction to the following:
10,$tilde water level below top of caeingt / , (ft.) Division of Water Reeounes,Information Pra wing Unity
(f itwter lcrof is abate ttuhrg,Rtc"�" 1617 Mail Service Center,Raleigh,NC 276WI617
11.Borehole diameters _iln,) 24b.Elir JAIR liK Welist In addition to rending the form to the address in 24a
Rota above,also submit one copy or this form within 30 days of completion of well
12.Well construction method: consitutnion to the following:
(i.e.suger,rotary,cable,direct push,etc.)
Division of Witter Resources;Undergmed Irjeciton Control Program,
FOR WATER SUPPLY WELLS ONLY. / 1616 Mall lief vkc Canter,Raleigh.NC 27699-1636
13a.Vldd(Rpm) I v Method of teat: ! 24c.For�'►'oter i nugly A 121 n welts: in addition to sending the form to
U� n y� the addrass(cs) above, also submit one copy of this form within 30 days of
13b.Aidn"on type: Amount: V t� t!' 1 completion of well constructionto the county hcahh department of the county
where constructed.
i
Fort"pW1 North Carolina Depnntnent of Enviro rneatai Quality•Division oi'water Resources Rovisw 2-32-3016