GW1-2021-00834_Well Construction - GW1_20210203

WELL CONSTRUCTION RECORD Foracd I Use ONLY:
This fo#m coo be uud for siugk or multiple wells
I.Well Contractor Information: 14.WATER TONES
Billy Kennedy mom TO DucTurnoN
ft ) R ^
Wdl Conuactur Name
p�,t A B. ft.
2VJ r'/ IS OUTER CASING turnout coned weld OR IJNFR Ha eeable
NC Well Connector Certification Number FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling R• AL s.25 to SDR-21 PVC
IC INNER CASING OR TUBING liecolibin,mal ebsed-loa D MAiEBW.
CorrrpanY Noma FROM TO IAML'TF.R 1TIiLTO1FSS
h ft
2. 1 Constractioe Permit N: 2� e / 7 is
iv,1 ull applicable well permits p.e.Cwnry.Score,Variance,fnjertian etc.J R g,
3.Weil Use(chock well ase): 17.SCREEN
FROM TO mAME1ER M.OTSIm TmrKNm MATERIAL
Water Supply Well: R rt in.
OAgricultmal OMun cipal/Public In. It. ip
OGeothermat(Heating/Cooling Supply) esidential Water Supply(single)
Ia.GROlff
❑Industriallconnuvrial oRmIdential Water Supply(shared) FIOM To auTTRfAL eMPucEMENr METntrosAMouNT
❑Ion anon 0 iL 20+ IL Bentonhe Hydrate ehipS in plaea
hIm-Water Supph� ',ell: B. n.
❑Momianng DRi:rovery d. &
In)ectWaWel: 19 S,4Np/GAAYF3,PACK ita inble LMruCEMGTMETHOD
OAquifer Recharge OCnoundwaRT Remediation fRDM To MATERAL
❑Aquifer Storage and Recovery ❑Salinity Barrier n n
OAquifer Test OStormwater Drainage p• it.
17Esperimental Technology ElSubsidence Control 26.ORILLING LOG y baddibOr sheen ifruxn
OTracer mom To
DFSrRIrOON <alw a ralFrat4 H<.
OGeoihennal(Closed Loop) It.
ft'11e
OGeuthermal(Hearin Conlin Return OOMer(ex lain under#2i Remarks) f/
4.Date W ell(s)Completed: _ eH
So.Well Location: 7 /J
MIIY rI �I JdA [/I •t "I'
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Fociilityylownew Name .{., ) Facility I/Dk(ifapplieebk) It. ft.46 (0 / NJ L( C �rSLfJ Xe R' n
Physical Address,City, it Zip 21.REMARKS
ndir
Parcclldentifiwtion No.(PIN)
County
Sb.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one leUlongusufgcieuQ •� �M ' /_ 1S '�d��
N „ J 1 Signm re f em bed Well Co-w-u r Di 1�
6.Is(me)the wen(s): 174maoent or OTemporary Jr,signing this form i hereby certify#hot the xrll(s)was(1rere)minimeted in accordance
with 15A NCAC 02C 0100 or ISA NCAC 02C.0200 Well Comoucu.StarMmds and her a
7.Is thisrepair to an existing wen: Oyes or o
If m
copy of IMs record lion bean pnn'ided ro the well owner
If#his is a noun.Jill tmr krox'n well crmelraction infornwtion and explain the nature of die 21 Site diagram or additional well details:
repair under.21 remarks searinn or ran the back ofthu funs. you may use the back of this page to provide additional writ site details or well
m
Fi Number of wellsnst
construction details. You may also attach additional pages if necessary.
c ra
Fo,multiple injection or o-uater er supply wells ONLY with the same consrrualu+n,)vamrt SUBMITTAL INSTUCfIONS
.submit uniform. // ,[•/
depth below land surface: i6 (fL) �• For All Wells: Submit this form within 30 days of completion of we
ll
9.Total well dip construction to the follmahng
F'ar multiple wells let oll<kpths ifoljituenl hex ample-3@200'aIW 2@IW) -
/� (h) Division of Water Resources,Information Processing Unit,
co
10.Static water level below p of using: 1617 Mail Service Center,Raleigh,NC 27699-1617
11 wa#er level o.lowe casing,use "
24b.Fo 1phretion Wells ONLY: In addition to sending the form m the address it
l 1.Borehole diameter. 6.2.5 pa.) 24a above, also submit a copy of this form within 30 days of completion of we
12.Well construction method:
War i _ construction to the following
(i.e.auger,rmary,cable,does[push,etc) Division of Water Resources,Underground InjectionControl Program,
11:36 Mail1 Service Center,Raleigh,NCC 27697699-1636
EFORATER SUPPLY W ELLS ONLV: Alf 24e For W to S Rply&Injection Welbi(gum)-__ D- - 6fethod of test: Also submit onecopyof this form within 30 days of completion of
granular hypochdnie well construction to the county health department of the county where
fxbon type: Amount: la�� constructed.
Revd_
Form GW1 Nosh Carolina Department atEm'ironrtRat and Natwal Resow<es-Division of N'ater Resources --,. �a'