GW1-2021-02458_Well Construction - GW1_20210901

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WELL CONSTRU!CTION REQ2 For internal Use On :
I.Well Contractor Information:
a.�
Ronald C. Cannady , 14 WATER
%Veil Contractor Name
2126-A
NC Weil Contractor Certification Number �:r'C J�V`4Cio U1111 IS OUTER CASING for r»u1 sod w b OR LiNE t rabic
Cannady Brothers 1�fa �► t >u" t'A.
3 R. M In. 54-0
CompanyNomc 61 1 G RT NO ed
2.Well Construction Permit H: G a aco0 93 MGM TO DIAMSM THICKNIMutL
List all appllydble Troll co mintction permits(I.e.111C rnrntp,State.Parlance.etc.)
3.Well Use(check well use):
7.SC EEN
1Vuter Supply Well: i DIA t MATERIAL
,Agricultural ®MuriicipaU'ublic n. n. in.
Geothermal(Hcatin(/Cooling Supply) sidential Wnter Supply(single) 3.3 n, 3 S n, in, e��S y a p 1/4
Industrial/Commercial 01tesideniusl Water Supply(shared) I&G OUT.
Irrigation MOAT IV 1 t 00 R MOUNT
Non-Water Supply Well: © R' rZ a R. dW1
Monitoiin Mccover, rt•
Injection n, n,
Aquifer Recharge ®Groundwater Remediation 14 SANDiC VEL PACKfifoonflablel
Aquifer Storage and Recovery 13Solinity Barrier ra°at I TO MATUR W, I U1111AC t T761TETHOD
Aquifer Test 0Stomtwater Drainage D n' n.
Experimental Technology OSubsidence Control R• n•
Geothermal(Closed loop) [3Traccr 211 DRII.LiNa LOa Ietti raddlttfl 1 t
TrROM TO n er, ras to stm no
Geothermal(HeatinILCooling Return) Othor cx Inin under 021 Remarks Q h. 1 D (L � (7
4.Date Well(s)Completed: a Z�Well litf)
So.Well Location:
Facility/OwncrNanicc� Facility IDN(ifopplicoble) R' R A!.
to—re, n. ft.
Physical Address,City,and Zip R' n
L o f t R 21.REMARKS
Cuunty Parcel Identification No.(PiN)
5b,Latitude and longitude in degrees/minuteslseconds or decimal degrees:
(if%vcll field,one latilong is sulTioI M) 22.Certification:
3 yJ .9,7 �`� N -��`a 'b �'56 $-a w a� 2
L_0�
6,IsOre)the well(s) rmanent or C)Temponry Signalurc of Cc— nificd WdjContractor T Date
p�y� 8),signing this form.I hen*,cert(If•that Use nsll(s)uns(•revel constructed in accordance
7.Is this a repair to an existing well: [DVN or eP, n'lih 154 NCAC 02C.0100 or ISA NCAC 01C.0200 Nell Conunfaton Standards and that a
IJthis is a repair,Jill out kaoinn trail canstnrctlort Irifirnttation and explain the nantre of the , copy 4f this record has been provided to the mall oumr.
repair under 1121 rentar/a section or on the back of thisfornr. 23.Site diagram or additional well,details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the some You may use the back of this pngo to provide additional well site details or tvell
construction,only I GW-I is needed. indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: Si MITTAL INSTRUCTIONS
9.Total well depth below land surface: %( (ft-) 24a, For All wells: Submit this form within 30 days of completion of well
Fur awhiple im/h list all dcptht)f tliffe rrrt(cowopte-3Q200'and 2@11)f) construction to the following:
10.Static water level below top of easing: (ft.) Division of Water Resources,information Processing Unit.
(fuuter Icvri is above casing,ate"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: / (in.) 24b.For Iplection Wells: In addition to sending the form to the address in 24a
Rotary above,also submit one copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) Method of test: 24c. ater Simply&lAl"don:)Veils: In addition to sending the form to
the address(cs) above, also submit one copy of this form within 30 days of
13b,Disinfection type: sx!n�-_ Amount: 20 b p PM comptciion of well construction tot the county health department of the county
where constructed.
Fonn G%V•1 North Carolina Department of Environmental Quality-Division o1%lcr Rosoutccs Revised 2-22.2016
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