GW1-2021-01092_Well Construction - GW1_20210305

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: ^�
v - 14.WATER ZONES
Billy Kennedy � ,' � • ti0 t"`` FROM TO DESCRIPTION
Well Contractor Name r' s� ft ft a
ft ft.
2834-A `� g� 3
r.
NC Well Contractor Certification Number 15.OUTER CASING for multit wells OR LINER if a licable
FROM TO DIAMETER TRICtdVE55I MATERIAL
Kennedy Well Drilling _ n ,`' p ry 6.25 is SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM To DIAMETER THICIQlESS MATERIAL
2.Well Construction Permit#: ")z o -00 0 d a s fL ft. in.
List all applicable well permits(t.e.County,Stale,Variance,Injection,etc.)
fL fL in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft ft. in.
❑Agricultural ❑Mun' allPublic
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft IL in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Itri ation 0 ft' 20+ ft- Bentonite Hydrate chips in place
Non-Water Supply Well: ft fc
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a ieable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage IL ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if meeessa
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION color,bardness somroek a eta
❑Geothermal(Heating/CoolingReturn ❑Other(explain under#21 Remarks) o R 1014 SO
ft /� ft.
4.Date Well(s)Completed: e�` -a I Well LD# ft c_0 fi• u �e'G�
5a.Well Location:
fL ft
,6JhaAy ► bofon ag f a- ft- b/o,,5k
Facility/Owner larne Facility ID#(ifapplicable)
O ft. fL
`IG i?a all'ova a,/Cll ft. ft.
Physical Address City,and Zip r
21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one lat/long is sufficient)
N w &`
Signature U10crtified Well Contracto Date
6.Is(are)the well(s): 2ermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
/ with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards ad that a
7.Is this a repair to an existing well: Elves or OKO 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#11 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
8.Number of wells constructed: I 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. ,,II SUBMITTAL INSTUCTIONS
7 9.Total well depth below land surface: � � (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi,Qerent(example-3@200'and 1@I00) construction to the following:
10.Static water level below top of casing: 30 (Lt•) 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: ;In"addition to sending the form to the address in
Rotary 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS 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
13b.Disinfection type:
Grandar Hypochlorite Amount: well construction to the county heilth department of the county where
L
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
I