GW1-2021-00251_Well Construction - GW1_20211213

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? HELL Cs7N_SNIEVC1I9IN ULM giw-nl For Intemal 11se only!
1.Well Contractor Information: j
Ronald G. Cannady „
Well Contractor Name
2126-A ILI rt. i fl, C-cia��La
i a(L ft.
NC Wall Contractor Cortinmtion Number is,OMR C " rot•afiYl Q ER ! bt
Cannady Brothers Well DrIHIng, Inc. on 7o sot M 7ta1AL
.. ft. ).0 R. r! In 5'4 p P t.2 L
Company Nome 1 t 1 R
2,Well Construction Permit f1: Dr L
List all applicable trell constntctlon perntlrs(i.e,1/1 ,Comrly.Stare,Variance.etc.) ft. A. In,
3.Well Use(check well use): o. ft. In.
ater Supply Wall- 'SCREEN
r I O - 11 A7T,RIAL
Agricultural [3Muntcs 4,blic U p, A, r to 1 S �lv Y�/L ,•.yv
Geothermal(Heming)Cooting Supply) _13Residentia)Water Supply(single) p n In.
lndustrial/Commerciai OResidendol Water Supply.(ehaied)
— I&GROUT -
hri Lionto AIAMIAL - I o
Non-Water Supply Well: n e) h (/
Monitorin Rccav R, fi.
rijectlon well: ft ft
Aquifer Recharge 130roundwaier Remediation 1 8 PA {cable
Aquifer Storage and Recovery Salinity Harrier ria a» o MATERIAL sA1Pi Ac T ROD
Aquifer rest ostotmwater Drainage J R• / �v s"N /tb (� ,
Experimental Technology j3Subcnca sid Central n• R•
Geothermal(Closed Loop) 07ralocr 20.b O
TO Run
iota
LOG low It*a
Geothermal Hcatin Coo►in Return Other ex lain under 021 Remarks
d ft. R. p ..
J1 d.Date Well(s)completed: /�"-t DZ�, Well IDO
t So.We Location: ^ t1
� D tt. A'
Facility/Owner Name Facility ID (if ap
�pplicable) //v n //1 n.
Physical Address.City,and Zip ~ y>r y y/ 1� A. I� n. M 1
County Parcel Identification No.(PIN) '
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Sb.Latitude and longitude In degreWminutcalsecoods or decimal degrees:
(if wail held,one lotilong is suMclonq 22.Certification:
G:ts(are)"the welts) PltlltBeAtl Or 0 remporary
S,ismiurcc o-Ccni�1 onttecta
By signing ibis form,1 hercbp cenUj that the anti/(s)ins(trerc)emurnteten in accordance
7,is this a repair to an e3dstlpq well. �or [3No Wilt l3A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Conovolon Standen*and that a
if thh(SO M1141r,fill 001 knottit wall mnstrucrion iryJbnnallon and explain the nature of fire roFy gflhts record ha*been protioled to the sill"vier.
t epntr under H21 rentarb aectina or on the back afthlsfmnt.
23,Site diagram or additional well details:
B.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well site details or well
construction,only I OW-1 is needed, indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled:
9.Total well depth below land surface: / U AM) 24e. For A Wells: Submit this form within 30 days of completion of well
1 i,r mithiple urllr list nil depths 1/dip"orae(arompte•3(112mp mid 201 w) constuetion to the following:
10.Slade water level below top of casing 8 f� 7 6 (it.) Division of Water Relnurc%information Crace:sing Unit.
(furrier(e el is above casing,arc"+" 3 1617 Mall Service Center,Raldgh.NC 276994617
11.Borehole diameter: (in.) Ub.Elir ififeedoll M1151 In addition to sending the form to the address in 14a
12.Well conatrucl(an metbodt Rotay above,also submit one copy or this form within 30 days of completion of well
construction to the following: 6
(i.o.auger,rotary,eabie,direct push,etc.)
Division of Water Resoatall,Uade%round Injection Cootrol Program,
FOR WATER SUPPLY
/WELLS ONLY: i636 Mall Service Center,Raleigh,NC 27699-1636
130.Yield(gpm) `r Method of tat:. 24c.Ear Witter SNIMIv&in1j&n Welly. in addition to sending the form to
�. the address(ca) above, also submit one copy of this form within 30 days of
13b.Disinfeeflon type: S Amount: v� 10/ completion of well construction to the county health deponmertt of the county
where constructed.
Form 0W.1 North Carolina Department ofEnttironmentel Qwiiiy•Division of Water Resources Rovised 2-22-2016
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