GW1-2021-00309_Well Construction - GW1_20211220

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LL GO NTRUCTIO RECORD WN-LI tot Intmill useonly!
1.WOU Contractor information,
R a nad
IV911 Cantraotor Name
2126-A
NC Avon eaa,��ta►eehina,lan rntna,� e,, � ;`''t` n. n.
Cannady Brothers WQ,If n t Inc. I�
o it sue.Company Nsmc o e) 3�
2 Well Construcliao Pta'ntit N: $!)� � �
List all applicable troll tansim tan purnt is(i.e.1110,Como%Maie,�'aManet,tiel
3,Well Use(cheek well use): a• R' in,
ater Supply Welit
Agtiuulhtrai ' M•'fo' V$ubiio
Ovolhormal(Hcot(nglCoo)ing Supply) b6oldomial Watersuppiy(single)
n, I n, I Is.
IndustriaVCommemiel ®Residoolial Water Supply(shared)
Non- ntot supply t.,4l: p n. L) ft. t 0
Monitnrin Millie m fh ft.
ee on :
Aqultcr Recharge Remediation
Aquirer Storage and Recovory 03alinity,9arrter mom TO A WAIT=
Aquifer Test Ostotmwatar 9ralnage v t• =11514
Exporimoninl Toohnology 13BubaMcnco Central ft.
Owthermal(Closed Loop) OTIVOIT
Oaelh al(H21tin in Rcwm) r3otlierfoolain,undoroll R a
b rt
J�'11 . /h
4.Date Wet"&)Completed-N��=-�-� Well ilkl Cat:,.,..
So.Well Localfonl n' 3 J ft. rrl S'
V u n. O R.
Fsoility/Owner Norm Facility lDx(if appilcoblo)
Phytkal Addtest.Chy,end zip
County fates[k colficalloa No.(PIN)
6b.Latitude and tettgkade in degrtWminutes/ee vwh or dedtm i deptes.
(if wall held,eta Watts is wmotam)
N W
6.1 nre rite wel► rtnanent or em rn ute o ouni ad Wait conaeator `""� rhic
>k ) (GRl3Pe � tm �'
it-a�gnitrg flt(r , I hm$),ctnj&that the umRhJ was rirm)murtrttcud In acrordeam
7,is this a repair to an exitfipg went DYOS or It� ulth 1 SA NCAC OIC,n100 or/SA NCAC OX.01at WOW Cmuinvilon SrWank and that a
)/lilt isT+Mwfry111 outs vwn siWl consrnwloilglbrnta►fan and axp the nalmt ajrht-. -COIiY'll ij'MOMd.hoo.Rean p"a'Mad-to tM,ttrtLaarx+— --
rnpalr rynclor HI,vn,anb sevilmm of on the hacrt 4l thts f".
. 23,Site dittgr»m or additional well dt:talbt
B.For GeoprobelDPT or Clowd4.00p Godbenttal Wallis httvhtg the same You may use the book of this page to provide mWitional wil silo details or well
construction,only I OW-t Is needed. Indlosto TOTAL NUMBER of wells construction dowils. You may also sttaeh additional Pages if"cowry.
drilled: EMUMM
9,Total well depth►elow land utt'facoc ,.�„L�" 3ffD ...........:lltt.) 24a, �X,d} t Submit this form within 30 days of completion of well
Finn multiple uvIle Usl oN depihs Vdowt faramptn Sfrjil0n'nnrl 1 My oonatntetlon to the following:
10.Slade Water level below top of C611481 i u (11.) olvialon of Water It"Ourm 1111bttlUltlon Preteens Unite
ff ialer(rtmt it abolte casing,are."+" 1617 Mail Setwlea Cater,Raidgh.NC 27699.1617
11.Borehole diameterl / t (la..) Ub.jXJWXjOyAt In addition to t wing the form to the adtil'oas in 24a
I L Well conbtrnetlen moithedt Rotary nbovo,also submit one copy of this;fbrm within 30 days of compktton of well
(l.o.sugar,rotary,cable,direct push,etc.) consitUation to the tbI►owing:
Oivbloa d Water 1imarces,1j"o igremad Isla tan Cotmol PhroArom,
FOR WATER SUPPLY WE1,L8 ONLY; Iad Mail Service t..aitter,%l ilo.NC 27690.1636
13a.Yield(gpm) , Method of test: //� W Fnr NWIr A 1.1k 8
to addition to sendin the form to
'nte oddmus(es) above, nlaa subm tl ono copy of this form within 30 days of
13b.MoIntotton type: Ameuntt P completion of wall construction to Ithe county heshh dopartmant of the county
/T 7 Y where constmoted.
Fann OW-I North Umolina Deparimo l of 0nvirontnantU t2ttallly•Division of water itesourcos Revised 7-22-3016