GW1-2022-04027_Well Construction - GW1_20220422

1 ELT G NcT LiC I ®NRECORD
For Intennt Use ONLY:
r! Thss form can t:e used far siagie W multple*dls "P
!Yell Contzacior3APnrmntioni
Arthur Wayne Canhady 14.WATER ZONES:
FROM TO DES"IMOrr .
West Caanaerorxse1 X-ft, Lye,
21 7A NC Wei!Conmactbr Certification Number 15 OIPI ER CASING for molt!cartzi sve3ls OR LINER f a licahte
Cannady Brothers Well Drilling, Inc. rRon! TO nLval�rEtt� THICi SS auTeaw
3t Sct.Yd Puce. .
Caiapsrig Tfamb 16.INNER CASING OR TUBING thermal elused•-loo ). 1
'A' FROM TO ER DIAMET THICKNrESS HATFAIAL it
2.Well Construction Permit R: VV C eU —��Q l�aj ft. fr.
Lisr al!appiirnble irdi permits Ire.County,State,Variance,:Infection,etc.)
3.Well Use(check well arse): 11.SCREEN
WatasuPPiy.Weil: FROM TO 13WHETE11 SLOTSIM THICKNESS MATERIAL �
' �.fn.
a4d..itural. ' � P Oil9tmicipaUPublic u3 4 .y. ��I S S it} . 9 u."L
ft
[Meothermal(Iiealing/Coolino Supply) ❑Residential Water Supply(single) in
❑industrnaltornmerciat OResidential Water Supply(shared) i L GROUT;
FROM TO MATERiM, EMPLACEMENT METHOD S AMOUNr
Ft'
Non Water Supply Well- fL ® el Sta4 nt/tvk.
ft. t'L
❑Monitoring ❑Recovery
injection Weli; ft. %
❑Aquifer Recharge l3GroundwaterRemediation 19.SANDiGRAVELPACK tfo licahie
Q wfe FROM TO. AM IVtAt. . EMPLACEMEXT METHOD
Aq ' r Storage and Recovery I7Salinity Barrier.
❑Aquifer Test OStormvrater Drainage 06.
ft. fL
OExperimental Technology ❑Subsidence Control
IA.DRU LING LOG:a8ach cddittonal shei:Ls If n
❑Geothvmal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hu&ess,saiStronk air ear etc.
OGeothermal(HeafinzfCodling Return) 001her lain under a2l Remarkks Q ft.. $11 .IL
t�f� � ° r� old fu r.�F
4,Date Weit(s)ConTh,I! d cli my, e
Qs fL P�'�y fu f°s neyrA r�r"'''t
SSa�a.'Well Loeation.' / °r ft. �yf� ft-
flat /t'o� I4 ft �+,,dit.
Facility/owner Nano Faeuity Mff(ifepplieable) A
:a 3 ft.
Physical Address,aty,and Z p !r O try
2L REMARKS l"a t
County Rupl Idnti6sxt on No.(PtN) A�
Sb.Latitude and LonghWe in degreeslmlauteslsecouds or decimal degt ens: 22..Cctt rlcatioD:
(if wellfield,one taVloeg is sufficient)
j1T 2� Y79tz7� �� 40" ? �Jr7�0*4
u+ .. N�
5i1pnture of Certified onC n\ liao o '" % Dste '
6.Is(are)the well(s): Evl"nx 'D t or OTemporary signing All onm I here cer•' Mot the nvell s im vein constructed in accardmtce
By g+rn8 I . b3'. �b' (1 4 l
wilh ISA NCAC 02C.0100 or ISA NCAC 02C_0200 Mall Construeuon Standards and that a
7.Is,this a repair to an existing well:. Oves or 15W copy afthfs record has been provided to the tall onner'
If this is a repair,fill out kncnm well construction wi rmodon and explain the nature of the
repair under 921 remanir section or on the back of this form. 21 Site diagram or additional weltl detniis: '
You may use tka back of this page to provide additional well site cetaiis or well
S.Number of wells constructed: " construction details. You may also attach additional pages if necemry.
For muliipfe infeNtan or non-wafer supply wells ONLY with Me same eonstiuulon,3vu can
submit one form. SUBiyl1TTA�L.HiSTUCTIONS
�} el
9.Total well depth below land surface. J (ft,) 24a. For All Wells: Submit thin form within 30 days of completion of well
For multiple wells fist atl depds IfdW�retrl(example-3(a}200'artd 2Q1W) construction to the following:
10.Static venter level below top of casft.: �e 0 M) Division of Water Resources,Information Processing Unit,
Ifcrater level is.abom orsing,we'+' ,/ 1617 Wit Service Center,Rol lgb,NC 27699-1617
11.Borehole diameter: �I (in.) 24b.For Iniec-020 Wells ONLY: in addition to sending the form to the eddress in
r {� 24aabave,also submit a copy of this form within 30 days of completion of wall
12.Well construction method: 1 d-� construction to the following: i
(i.e.auger,.wt&y,cabs,d'unect push,etc.) '
Diviisiou of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mall5ervioe Centers Raleigh,NC 276994636
13a.Yield(gpua) Method of test � � � Z46 For Water Supply&Infection Wells:
Also submit one copy of this form within 30 days of completion of
13b.IDistofection type: Anwuat: i f) L9 10 P- ,well construction to the county health department of the county where
construct d.
Form GW-1 North Catalina Deparbueffi of Environment and Nahnul Resources—Division OfWftt Re4w== Revised Augtm 2013