GW1-2023-01430_Well Construction - GW1_20230208

t
M,LL CONSTRUCT N RCORD
For Internal Use ONLY:
Thise form can be used for single or multiple wells
1.Well Contractor Information:
Arthur Wayne Cannady 1a.WATER ZONGe
PROM TO I W.SC ipnoN
Well CotitractorNama ,(�<' ' (� ft. V R.
� 2125-A ` _,
NC Well ContrttctarCcrti6cadonNumber FR r' Q Zl'ZJ I&QUMRCASING formulti-Uq wills OR LING Ea itcabio
F -- J RROM TA D MIST R TmCKPIFBS MATERIAL.
Cannady Brothers Well Drilling, Inc. ^ fL 1as FL In. Sc14J VL
CompanyNmno iv+.+•++ ___
�eve���� 1b.INNI{R CA.ING OR TI111TNG eothormat elosed•lao
PROM TO. DiAMaT.R THICKNESS 1ATERIAL
2,Well Construction Permit Or ft. tL In.
List all applicable well partalrs(I a Coumy,Slate,Vartmrce,Iirfectton,eta) ft. ft, in.
3,Well Use(check well use): 7,SCRGGN
Water Supply Well, FROM TO DL1MRrER SI.OTSIZE THICKNESS MATERIAL
e_ortrgiryirni ON�micipaV.Publis /Z ft. 1yo f6 (�Ih tu. (�)5 S�Ya C-" ­S
DGeodtermal(Heating/Cooling Supply) OResidentiai Water Supply(single) ft, ft. In.
❑Industrial/Commercial OResidentiaf Water Supply(shared) 19'GROUT
ptiAM TO MA L ChIPLA(Jnmagw MRTNAD A AMOUN
DIrri lion v
Non-Water Supply Well: R,
-- - DMonitoring ORecovery
Injection Well, _
Dkuifer itechargo OGroundwater Remediation 19.SANDIGRAVGL PACK a ticable
C7Aquffor Storage and Recovery OSalinity Barrier FRonI TO NATORIA1 I EMPLACEMMT MCTROD
OAquiferTest DStornawaterDminage 1 v .l�J
fL ft.
OExperimental Technology OSubsidenee Control 20.DRILLING LOG fnumdt additional sheets If secs
Oaeothermal(Closed Loop) Q'I'mcer FROM I TO nPSr7UP'fION color trirdace saiUrsekt a in dit etc.
OGeothermal(HoatinWCODligg Rettlm OOther ex lain under tl21 Remarks ft, Al ft, B.rAtl>M,
4.Date Well L
s)Completed: l - 7, d rL ft' M J><. .
welt Ia>+
"' O d ft-
$a.Well Locadon: 16 d ft- b ft. C006AA11
J Annam, a @ d•g —GM IL ft,
Facithy/Owner Nanlo Fnoitity 40(if appiicabie) iG ft.
GJIJk a/ 14c-�W c_ A& rL ft,
Physical Adess,City,and Zip 31.RFKARICS
County Parcel Identification No.(PiN)
fib.Latitude and longitude in degrees/minatiWseeonds or decimal degrees: 27.Certification:
(if well Auld,one latllong is sufficient) G (0&fCQrflr1W'ffe1U
e
t3 5/ ° 7 3 S S N ? O ` �1()3 y W _lsuDI h,0 O-� .f2
�� � Sigrui tebntmctor y Date
6,Is(are)the wefi(s): aBel7nanent or OTemporary
By slgrrhrg rh/s form,1 hereby certify drat lira.tvall(s)tear 11vero)rnrrstnrcted hr attordarrce
with 15A NCAC 02C.0100 or 13A NCAC 01C.0200 iVall Construction Starro'ards mid that a
7.Is this a repair to an existing well: OYes or f(Wir� copy ojdris retard hat been provided to die rrell ouvror.
{f drlsls a rupah;Jlli ant knatm well c»nrirncilmr btlornrafion and expfo)a the aa0vo ojd�e _
--_�--_-� repolrlarderJJ21-roawnFsxacWrndr_ar�habackafrlrisfamr�_ _� _ 23.Slte.drngram oraddlitonal well detallS:,_
You may use the back of ihfi pege;tw�tovide addiuoruil weft stte'dctuils or well
8.Number of wells constructed: construction details. You May also attach additional pages if necossnry.
Fur mtthlple I/yeetion or non-u,aicra apply welly ON1.r ivllh r/m some eviWacilon,yorr can
submit orra form. l ,` SUBMITTAL INSTUCTIONS
A.--tat iicu'u'epi,i uc)uti iflrtri brii'°ai,rc: J- (fL) 24 Fnr All WPllet Submit thin,form within 30 days of completion of well
Fornndtiple wells list all daliths ifdVerow ieratirple-8(g 2000'artii2@100') construction to the following:
10.Static water level below top of ensing; r f�Jl (ft,) Division of Water Resources,4!fOrnuition Proeessing Unit,.
.(/'wafer Iaral is abova eosin Ilse"•t' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter:r�(in.) 24b.Pot lg(gg nn plk ONLY: 1In.addition to sending the form to the address in
t A._ _ 24a above,also submit a copy of this form within 30 day$of completion of well
12.Well construction method: FIL-1 construction to the following
(i.e.auger,rotary,cable,dkect push,etc.) '
Division of Water Resources,Underground injection Control Program,
TOR CATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
i
13a.Yield(Upon) 60 Method of test:�� 24a rot Water Supply&iRlection.Wells:
Also submit one copy of this forth within 30 days of completion of
13b.Disinfection type- UZ s--i Amount:_.�(-(-R��_ Well construction to the county health department of the county where
constructed.
\\ Form 0%V-1 North Carolina Department of Havironmeat and Natural Resources-Division of Wotur Re...... Revised August 200