GW1-2021-02462_Well Construction - GW1_20210527

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WELL CONSTRUCTION RECORD(GW-1) For internal Use Only:
1.Well Contractor Information:
Ronald G. Cannady
14.WATER TONES
FROM TO DESCRIPTION
Weil Contractor Name a w R. R. C,0d-- e
2126-A
NC Well ConuactorCer ification Number 15.OUTER CASING fortn'ulfi-CaW wefts OR LINER fa licable
Cannady BAL
rothers Well DrilliAM
ng, Inc. FROAf TO rL a5� f). I I DI/, R THICI:NLss Po G MATE,
tn. y
Cnmpnny Name 16.INNER.CASING OR TUBiNG eothtrmvI-cImW400
2.Well Construction Permit#: FROM To DIMIETER THICKri"b MAMMAL
List all applicable trail consinretion permits(i.e.U1C.Count;State.i ariance,etc.) R. fL in.
3.Well Use(check well use): R. tt. in.
17.SCREEN
Writ upply Well: FROM I TO DIAMETER I SLOTSIZE ITIHCKNFSS MATERIAL
gricultural �MunicipaUPublic 7L! 3 ap R. .= iR• .0 yt) p QGwwf,l �ll✓
Geothermal(Heating/Cooling Supply) DResidential Water Supply(single) n. It.
IndustriallCommercial C)Residential Water Supply(shared) I&GROUT
irrigation FROM TO MATERIAL F.AIPI.ACEMENTMETHOO&AMOUNT
Non-Water Supply Well: n. � h.
Monitoring 13Rccovcry R n•
Injection Well:
Aquifer Recharge ®GroundwaterRemediation 19.SAND1GItAVELPACK if 'liarble
Aquifer Storage and Recovery OSolinity Barrier FROM TO MATERIAL EAfPLACUIE1vT METHOD
r
Aquifer Test [3StormwatcrDrainage Sv ". 3�J a. 44, /G ten_
Experimental Technology 3Subsidcncc Control R. n
Geothermal(Closed Loop) [3Tmccr 20.DRILLING LOC ISttiieh additional'she hi if
FROM TO DESCRIPTION lcolar.hardnesm solVnKk type,gmm she.etc.
Geothermal(Heating/Cooling Return) nOthcr(explain under#21 Remarks) (0 R. 3( ft 7a Q + v
4.Date Wells)Completed-1 Q�A/ Well iD# 3 fJ 0' FS O R' BLc-'�` d t°b u -7 5 4�
Sn.Well Location: J qV
(jLr �Y►s.N" / ft. 119S
Facility/Owner Name Facility IDN(if applicable) 1�S H' a a() R• r-/'s�'�'Q I�s ? ,G-S "'
Physical Address,City,and Zip3 ILL �(ov R• 3a fL
21.REMARKS
County Parcel identification No.(PIN) Illi
Sb.Latitude and longitude in degreeslminuteslseconds or decimal degrees:
(if well field,one IaUlonb is sufficient) 22.Certification:
,35°, oVog Vl N -7�Sa.i�v�o J 3� W �u�t f- /4<�r boa)
Signature of certified Well Contractor
' Date
G.Is(are)the tvell(s) ermnnent or �Temporory
By signbig this form.I hereby certh,that the ivell(s)star fume)comtntcted in accordance
uith 15A NC.•IC 02C.0100 or 15A NCAC 02C.0200 li'ell Contraction Standards and that a
7.Is this a repair to an existing well: �Ycs or
if this is a repair,fill out known urll constnictfon hifonnation and orplain the nature of the _ copy of this record has been pr mYded to the sreH mt+rer.
repair under P21 rrmarhs section or on the back afthis form. 23.Site diagram or additional well details
S.For Geoprobc/DPT or Closed-Loop Geothermal Wells having the some You may use die back of this page to provide additional well site details or well
construction,only 1 GW-1 is needed. Indicate TOTAL NUMBER of wells construction details. You may also attach additional pages if necessary.
drilled: SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 3 A f(n•) 24a. For All Wells: Submit this form within 30 days of completion of well
For mohiple uvils list all depths ifdfflemit(example-3Cnonn•and 2 a 101r) construction to the following:
10.Stntic water level below top of casing: (0 U (ft.) Division of Water Resources,Information Processing Unit,
If urirer kill is abmr casing,use"+" 1617 Mail Service'Center,Raleigh,NC 27699-1617
11.Borehole diameter: T (in.) 24b.For Injection Wells: In addition to sending the form to the address in 24a
Rotary above,also submit one copy or'this form within 30 days of completion of well
12.Well construction method: 'I construction to the following:
(i.e.nubcr,rotary,cable,dircct paste,ctc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 276994636
13a.Yield(gpm) + McWod of tst 24c.For Writer Suo—W&iniection Wells: In addition to sending the form to
e ^_
the addresses) above, also submit one copy of this form within 30 days of
13b.Disinfection type: Amount: 212 J npm completion of well construction to the county health department of the county
where constructed.
Form GW-I North Carolina Department of Environmental Quality-Division of Watcr Resources Revised 2-22-2016