GW1-2021-03380_Well Construction - GW1_20210607

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bill Kennet 14.WATER ZONES
Y Y FROM TO DESCRIPTION
Well Contractor Name O ft &
2834-A ft ft.
i
NC Well Contractor Certification Number 15.OUTER CASING for multi eased wells OR LINER if a licable
FROM TO DIAMETER THICRNPSS MATERIAL
Kennedy Well Drilling 0 fL 7 fL 16.25 b SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING 6mothermal closed-loop) I
,r FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ,1;3Z2 t1 DD©�t'o�J ft. ft. �•
List all applicable well permits(i.e.County,Stale,Variance.,Injection,etc.) ft. ft in.
3.Well Use(check well use): 17.SSE
Water Supply Well: FROM TO DIAMETER .SLOT SITE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. ird
❑Geothermal(Heating/Cooling Supply) Anresidential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
01rrigation 0 ft 20+ ft. Bentonde Hydrate chips in place
Non-Water Supply Well:
ft. ft
❑Monitoring ❑Recovery
Injection Well: fa ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft
❑Aquifer Test ❑Stormwater Drainage
ft. ft j
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if nets
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIP ION color,hardnps sontroek e n sim etc.
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks) ft ft. k-
J ft 30 ft `�ra)/2
4.Date Well S s)Completed: dV-oZ-�Well ID# � � w
13 n S
S�a(Well
j,Location: ft.. A;T tt l&c
Q0"I ft. ft
Facility/OwncriName Facility ID#(if applicable)
�`'/� /' /r- /`// /� -/ ft ft t
C�c,�le �i✓p /�i1 ft
Physical Address,J City,and Zip
21.REMARKS
?7 3©sz�.� JUN
Couuty Parcel identification No.(PIN) 1.1111t
r.0
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
(ifwell field,one lattlong is sufficient) 22.Certification: pVJ1?Seri1On
N W L<'�- s--as gvv�
Signatur Certified Well Contractor Date
6.Is(are)the well(s): ®Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or iSA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or GKo- copy ofthis record has been provided to the well owner.
If this is a repair,fill out known well construction information and explainthe 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: 1 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. �r SUBMITTAL INSTUC IONS
9.Total well depth below land surface: PAs (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'and 2@100) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use•'+" 1617 Mail Service Center,Raleigh,NC 27699-1617
It.Borehole diameter: 6.25 (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
p 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: /` /'V 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) 3 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: Amount: �_
granular hypocholdte well construction to the county health department of the county where
�t�D
constructed.
s
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013