GW1-2021-07758_Well Construction - GW1_20211116

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WELL CONSTRU_C110 REC'CORD(GW-1) -For-Rite-ma Use y:
1.Well Contractor information:
Ronald G. Cannady >v
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Well Contmstor Nnmc � R,
2126-A �, Yin
NC Well Contractor Certification Nuffdw 1 OUTARCA8 NG fornail 9 L SIV bit
Cannady Brothers Well Ddifing, Inc. FROM TD ) 1THICKNESS �lA L
35 n. ,'L, In. © p v
Company Namc ) I&INNER 1 OR BIN
2.Well Construction Permit 0: G / DOa a u t
List all applicabla mll construction jownilts fl.e,flit,County,State,Yarialtm eta)
3.Well Use(check well use): In.
Water apply a t7
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� r 51-4 r 1 M 'rRRtA6 L,Y�•y
gNtherma
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nj
Agricultural 6rida"awl
pal/('ublic �• rrl&Ocothcrmal(Neating/Coo ing Supply) Water Supply(single)IndustrialOCommercial DResidential Water Supply(shared) OUT
bri tion I En ovk uNr
Noa•Water supply Well: • /' R• /4 art.p P (T
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ee on well: a. n.
Aquifer Reeborge [30mundwater Remediation
Aquifer Stomge and Recovery (3Salinity Barrier �aam � PACK MA if �.aAL cE METN
Aquifer Test E)StormwaterDrainage 2D R• R• fr b a.
Experimental Technology Subsidence Control n. R.
Geothermal(Clo®ed Loop) D[1 racer Na DR!"a u tf tic
Gcothetmal ticati ing Return} nOthar htin under 021 Remarks R.
rb oc .
4.Date Wells)Completed: 1' aZ Well 1D# h• R'
So.Well Location: �Q R' ft.
R.
Facility/Owner Norm S AAJ^ Facility IDltfifapplicable) R• n• Y
-.- It. ft.
Physic:)Addrm.City.and Zip
5 —AM NOV 2U21
L.2 Z 22?-?92 y : �M
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dWR Sal.i iJN
t:uunly Parcel identification No.(PIN) PROCESSING
Sb.Latitude and longitude in degreeslminututweendit or decimal degrees:
(if.tvcn iklJ,one iatAong Is sulfrciem) 2L Certification:
OJQJ 04=4i /awe "a
6.is(nre)the wen( mensal or [31'emgarnry
siotwtarcco Cktt foil Wall contractor ' Date
Ay s(rdug this 0014 l hereby cm(fp that the ueilfs)uxu hre►�ratsnrrcted in aceordanec
T,is this n repair to an exisdog well: C)Ycs or i Wth 11A NCAC 02C.0100af)or f!A NCAC o2C o200 Well2onsri u ion Stan-efts and that a
If this is a►ropair,f ll out knoun aril construction it)fermathm and explain the nature ojthe rota'gfihts record bar been protdded to Aw uvil onmr.
mpair tinder 1121 rmiarb sevann or on the back ythtsfotm. 23.Site dlagram or additional well detatb:
You may use the back of this page to provide additional well site details or well
B.For CeogrobelDt'1 or Closrtl•Loop Geothermal Wells having the same
construction,only I OW-1 is needed. Indicate TOTAL NUMBER of wells construct?on details. You may also attach eddi�onal pages if aectsamy.
drilled;
9.Total well depth below land surface: „p 0 24a. bg All ells, Submit this form within 30 days of completion of well
For.ntdtip a le arils list all depths if tWerent(example•Jp1an'mxl 2 to I10) construction to the following:
10.Static water level below top of casing: l (R�1 Division of Water Resources,information Processing unit.
{fussier teal is abort casing,Otte *" 1617 Mail Service Center,11111i1119111.NC 27699.1617
11.Borehole diameter 4h.far inieon}( t to addition to widing the form to the address in 24a
12:Well construction method: RRotaryabove,aim submit one copy of this form within 30 days of completion of well
— — construction to the following:
(i.e,auger,rotory,cable,direct push,etc.)
DhWon of Water Resources,Underground injection Control Program.
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Ratetgh,NC 276"4636
13a.Yield(gpm) /D Method of toot: I 24c.Fgr Witcr Supply tic Inis�n Waits: In addition to sending the f8nn to
the adilmas(cs) above, alma submit ono copy of this form within 30 days of
i3b,Dhdri ketion type: Amount: .70 0 10Ip/J9 completion of well constractioa to the county health department of the county
where constructed
>:onn OW-1. North Carolina Depatiment of Environments]QW111y-Division of water Rem' RarisW 2-22-2016