GW1-2021-03374_Well Construction - GW1_20210607

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WELL CONSTRUCTION RECORD For Internal Use ONLY: j
This form can be used for single or multiple wells +
1.Well Contractor Information:
Billy Kennedy � 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 7 2021 gg-ft. 0 t,,1
2834-A 8 ftCASING
�Ptf°( r3410 ft
A.
NC Well Contractor Certification Number 11��°CEC51l4g u¢llt J&UTER form DIAMET was O LINE F(i s h MATERIAL
Kennedy Well Drilling DER Se 10n ft ft 6.25 in• 188-21 Galvanized
Company Name 16.INNER CASING OR TUBING eothea mat dosed 1
FROM TO I DIAMETER TMCI04M I MATERIAL
2.well Construction Permit#: 173 q U)E L A(a 1 ft. fr. in.
List all applicable well permits(r.e.County,State,Variance,Injection,etc.)
fr. ft, is
3.Well Use(check well use): 17.SCREEN
Water Supply Wen: FROM TO DIAMETER SLOTSUE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public fL Ift
in.
❑Geothermal(Heating/Cooling Supply) 21<'dential Water Supply(single) ft. m
❑lndustrial/Commercial ❑Residential Water Supply(sham) 1R-GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
01rrigation It W fL Bentonite Hydrate chips in place
Non-Water Supply Well:
ft
❑Monitoring ❑Recovery
Injection Well: & fL
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM fr. ft.To MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO nFs oN color ardnem soiUrvck IM zrain size,eta
❑Geothermal(HeatingtCooling Return ❑Other lain under 421 Remarks O & 5"' I
ft. ft
4.Date Well(s)Completed:J' 7 A Well EN
ft. fL _ G
5a.Well Location: J��r ft
Phr 1 A ut^g'e ss ft. n
Facility/Owner Name Facility ID#(ifapplioable) ft. fL
S 1{-t ,1y9 y fL ft
Physical Address,City,and Zip 21.REMARKS
A1 &im a e,
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)
� Signature4O ed Well Contractor Date
6.Is(are)the well(s): a ermanent or ❑Temporary By signing this form,I hereby certJ&that the ivell(s)was(were)constructed in accordance
� with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or z copy of this 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 of this 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: f 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: (IL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfdtjferent(example-3 i@200'and 1(a)1001 construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use..+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
IL Borehole diameter: 6.25 (in.) 24b.For Iniection Wells ONLY: in addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Ada e 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) Q?O Method of test: 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: HTH Amount:^ well construction to the county health department of the county where
constructed.
Form OW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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