GW1-2021-02457_Well Construction - GW1_20210527

vdELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
Ronald G. Cannady 14.WATER ZONES
FROM To DEScruP ION
%yell Contractor Name R, Uj� R.
2126-A fL T R.
NC 1Vc11 Contractor Certification Number 15.OUTER CASING for multi-ensed wens'OR LAVER f an ticable
Cannady Brothers Well Drilling, Inc. �oM TO DIAMETER THtctctc0D 'MATERIAL
R. 3 � R. .,v; in. �(, � PUt.1
Company Name ) / 2 i 16.INNER CASING ORTUBiNG cothe taalelosed-loo '
2.Well Construction Permit#: �"G �`/ w�o 3 J FROM TO DtA11tETER THIC6NE55 11A7ER41L
List all applicable well construction permits Ae.UIC County,State.1 ariance.etc.) R R. to
3.Well Use(check well use):
17.SCREEN
Water Supply Well: FROM TO I DIAn1LTER sLorslzE THICKNESS MATERIAL
Agricultural �MutiicijraUf'ublic ? R. Y-A R. >H ia• D) 1/� �+c✓`' � /wr
Geothermal(Heating/Cooling Supply) 51t4dential Water Supply(single) R R, in
Industrial/Commercial 13Rcsidential Water Supply(shared) 1&GROU3
Irri ation FROM I TO MA IAL IEMPLACEI1fENT61ETHOD&A IOUHT
Non--Water Supply Well: O R. CD ft. Paz"
Monitoring- .,- - Recovery R, R.
Injection Well: R, R.
Aquifer Recharge Groundwater Remediation 19.SANDIGRAVEL PACK if a licable
Aquifer Storage and Recovery Salinity Barrier FROM TO -MATERIAL EMP CEMENT METHOD
Aquifer Test 0Stormwater Drainage v�'1
Experimental Technology E3Subsidencc Control
Geothermal(Closed Loop) Tracer 20.DRILLING LOG ettiah additional sheets if aecessa'
Geothermal(Healin Coolin Return) Othcr(explain under 921 Remarks) FROM TO DFSCRIPTIO?4(cotor.hardnas,saturock t rn sin.ere.)
n- R" T
4.Date Well(s)Completed: Well[DIN R' o?A R.
5a.Well Location: ft.
ft.Facility/owncr Nanw Facility ID0(ifapplicablc) R. a. R ,- IT:
R.
Physical Address,City,and Zip R. ft. 2 7 20
21.REMARKS
e:,•t �rG�nSS'C'io 41
11
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degreesiminutcsfseconds or decimal degrees:
(if well ficid,one laillong is sufficient) 2L Certification:
G.Is(are)the tvell(s) rmnnent or 131Tempornry
Signature of Certified well Contractor Date
/ By signing this form.i hereby certify(bat the nr11(s)"us(IMv)constructed in accarl0 cc
7.is this a repair to an existing 1-well: [3Yes or li.l+'" airh 15.4 NCACO2C.0100 or 15.4 NC.4C 02C.0200 11'ell Construction Standards and that a
Ifthis is a repair.fill out Awotm aril construction Information and explain lite nature of the cap)'of this record has been proidded to the uvil turner.
repair under 1121 remarks section or on the back of this farnh. 23.Site diagram or additional well details:
8.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 GW-1 is needed. indicate TOTAL NUMBER ofwelis construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 00 24a. For All Wells:' Submil this form within 30 days of completion of well
1-or multiple ue/Is list ail depths ifdierent(eromple.3Qa 2011'and 2@1(191 construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If upmr level is above casing,um"+" > 1617 Mail ServicelCenter,Raleigh,NC 27699-1617
11.Borehole diameter: L.5 (in-) 24b.For Injection Wells: In addition to sending the form to die address in 248
Rota above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: ry construction to the following:
(i.e.auger.rotary,cable,direct push,etc.) i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service'Center,Raleigh,NC 27699-1636
13a.Yield(gpm) '2_-___-_ Method of test• _ 24c.For Waiter Sannly&Injection Wells: In addition to sending the fann to
the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: g-c-�'Jplom completion of Weil construction to the county health department of the county
where constructed.
I
Form GW-I North Carolina Department of Environmental Quality-Division of Watcr Resources Revised 2-22.2016