GW1-2021-01091_Well Construction - GW1_20210305

WELL CONSTRUCTION RECORD r.
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For Internal Use ONLY:
This form can be used for single or multiple wells '
1.Well Contractor Information:
14.WATER ZONES
Billy Kennedy FROM TO DESCRIPTION
Well Contractor Name ^,� ; cL ft. r-�
2834-A ^m ' % ft. b y►�
NC Well Contractor Certification Number 15.OUTER CASING for mal' wells OR LINER if a Hcable
�i`'� NWNER
TO DIAMETER THICI4VFSS MATERIAL
Kennedy Well Drilling ft- 6.25 la SDR-21 PVC
Company Name CASING OR TUBING edthermal dosed-looTO DIAMETER THIC104M MATERIAL.2.Well Construction Permit#: �I q- DOOD a orgo ft. in.
List all applicable well permits f.e.County,State,Variance,Injection,etc.)
ft. f6 is
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft in.
❑Agricultural ❑MunicipaliPublic
❑Geothermal(Heating/Cooling Supply) PfGidential Water Supply(single) tc ft. in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
01rri ation 0 ft' 20+ ft- Bentonite Hydrate chips in place
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. %
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifs Hcable
❑Aquifer Storage and Recovery dSalinity Barrier FROM ft. ft.TO MATERIAL I EMPLACEMENT METHOD_
❑Aquifer Test ❑Stormwater Drainage
ft. It.
❑Experimental Technology ❑Subsidence Control
20.DRILLM LOG attach additional sheets if ueces
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness co0lrock a dze,eta
❑Geothermal eatin Cooling Return ❑Other(explain under#21 Remarks f4 & t -
ft. — fL F,
17fIll Ity 6'.
4.Date Well(s)Completed:�- a 1 Well IDSE R f" 646
5a.Well Location: fL fL
i6ttoro'-s-S l 0VI ft. ft.
Facility/ Name Facility ID#(if applicable) ft. fL
ft. It.
Physical Addre ,City,(ind Zip 21.REMARKS
7G ti Qgs?S 2 2
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one laUlong is sufficient)
��rm Signature crtified Well Contractor Date
6.Is(are)the well(s): l3Peanent or ❑Temporary By signing this form,I hereby cer16 that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or OK copy ofthis record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back ofthis form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: / construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: (a (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths lfdijjereni(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: 01- (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter- 6.25 (in.) 24b.For Infection Wells ONLY: iIn addition to sending the form to the address in
Rota 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Rotary construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELL_S ONLY- 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
GrihAr Hypochlorlte well construction to the county health department of the county where
13b.Disinfection type: Amount: la Dz
constructed.
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Form GW-1 North Carolina Department ofEnvironment and Natural Resources-Division of Water Resources Revised August 2013