GW1-2021-00302_Well Construction - GW1_20211229

ff``,,CON9TR�(�'�'iTIO�(��(� a� or nta�la � � �• :�,- ,
.n t �.�i+rnrr�rrn, i.,iti�3wr.r.r+`:.n•�li�'9Grir e.,r$r.��
f:Well Contraetor lallarotation.
rnnadY .
Woll fontraaator Noma INT TO
-A 2126 �. '
NC Wall Conindarco"Ififtlon NMI"
Cannady Brothers 911..�...Pr1Wng:, Inc.
.�..�.. r� r.. ..,
Catnpany Netnc
4.wet11 CaAsiructian PertnlrN:_-l 9 _: y 9 I ao
l 1 all WOW IMI Mtxtnmro111"1 s 11 e,VIC, 3tat�,^l wteike etc j n• in,
3.Well VIC(cheek troll ttse):
fA
n -o t
Ruroi 13 vpabtic n. n. a =- C,94"V
UM
eriml(Heating/Cooling Supply) M I WaterluWy(single) Pt)Cr '
fistlCommerotoi ORe ddemial Water Sup ily(sham d)
tarBup y r p tr. v ft. �i3riL ihn e .
ar Rr 9tomge and itecovery 0tiallnity RamesrrTest C)BtomlwaarDminap �v it.imon►al Teahnotogy DBUbsldetce Controlermal(Closed loop)tt t Rewm intutder
4.Date �t.4r. c .y..H.i c. 30-0
Sa.Weti l,taHont t ►:' .-. - p n'; w c.1C
.tt:. _ : s
F ilf�yltiwaerNaina �' Pea►litylDhttfoppitcutik) a +� ,ZJY
plpalcal AdAms.Chy.and zipMom
t
Cuun►y P"I l"111eeiina Na.MIN)
Sb.l alitntb and loagitudeto degr+a WmJnuta Wmvds or tjednntt dWm.-
Orwell Atli,ono Itiltong is OWNI I) Ccrtiticattont
0.is(ore)me well(t0�nent or C'ireolperary 1FRvM o ,/gym a comma imtc
MV
7.Is hbartr IrtorknotM#ft caumrcltou.l015rntaMot►aD�. ainlhemrHwe INe_ 31M) ArA 02e.rdhol�,pt,o► C CQhe.0"O ass !bMi cawn+e+tdln and
9.Is this a repair to an exlatlns rreilr er Na oiG'.otoo Well tlorurn�crlau alra>H►aner sea roar o
arrN carter.
ropers under N21 nen,nr+t t xerttnn or an ON back qt rhltJwrn.
23.tlite dlgrom or additional treti dttativ
B.For GooprobvMPT or Cio1a -Imp Geothermal Wells having the same You may:tisO the back orthis Palle to ptavidc additional*W site details or well
eonstrucNon,only I OW-1 LIS needed, fndicato7MAi.NUMBEft of wells nallt. You may also numb additional page ifnescmery.
drilled:
9.Total wolf depth allow►sad sutfitct G iw� _r...rr.........:(1M) A6 &C.Ali VA Submit this lbrm within 30 days of completion of wall
Few mill"Oulu lar all dip►ke(rdowl Para Wa11'and(§ffm Gory���to 10 Bowing:
10,staAe water 18"1 below tap pf entiag: = S ..,. _(M) Division of Water aetanrtk tnlbrautba Pr ins Unit,
(/tmltr(e:el!r abatrr ttfat►ge,Arc'+^ 1617 Hall Serft Collar,Rtll b.NC 27699hiA11
t 1.Befftle dinmeterr ► (tn.) 24b.per latlI ft Wellst is addition to eettding ttte(rant to the add=in 24s
*MIRoWyt"vo,aim submit ono copy or this fbmt within 30 days of completion of well
V.Well toBtttruellO, tat owb, 10.) conatrusuon to the lbitaw=
(Is.nu�r,tottry,cable,dlnxt push,ate.)
Ditdelatt of Water pAmoumf*W& Wronad injection Centtret P roRrem,
FOR WATCR SUPPLY W9i.11.8 ONLY: 1636 Mail 6eavlee Catatvvc tt2e1**:IVC 2969 I06
13s.Yield(gpm)_r o Mothod of teat.. ,d 1 A- ..r. 24e.lta�gC 1j111111h it 111100i to addition to sending the form to
the o0diess(cs) above, alma aubbmlt;one copy of this tbfm within 30 days of
13b.DMatla**tyW' Amoamt O d AOe complation of well Construction to the county health dopsomea►or the county
Mtge eorttttttcted.
1�-f�f
Ftxnt OWI Nom oralim DOWttttnt of enviro "All!Quality•Dlvistttn of WOW RmtcPm � Raviwd 142-2016