GW1-2021-03523_Well Construction - GW1_20210607

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information:
Bill Kennedy 14.WATER ZONES
Y 1y/ FROM TO DFSCRUMON
Well Contractor Name O fL S ft
2834-A I 14-c-ft. e1v
NC Well Contractor Certification Number I&OUTER CASING form ed wells OR LUQER if a ticabl
DIAM e
FROM TO ETER TFI.CKNESS MATERIAL.
Kennedy Well Drilling fi ft- ft 6.25 i° SDR-21 PVC
Company Name / I&INNER CASING OR TUBING olbermal closed-loop)
2.Well Construction Permit#: aoa I ^OOOO©ec—V O FROM TO DIAMETER THICIIN6SS MATERW
List all applicable well permits(i.e.County,Stale,variance,Injection,etc.) ft ft in.
ft ft in.
3.Weli Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑M lelpaliPublic ft It. is
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) f' ft' rn
❑Industrial/Commercial ❑Residential Water Supply(shared) IS-GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft- 20+ f' Bentonite Hydrate chips in place
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
ft. ft
QAquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG atheb additional sheen if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DES ox or,hardness soft/rock tyM grain she,etc
❑Geothermal(HeatinglCooling Return ❑Other(explain under 421 Remarks) ft O ft clktl
`
4.Date Well(s)Completed: Well ID# O �n �'FdrPi
5a.Well Location: ft. ft.
A 1 .t3 u e 9_es 5 ft. ft.
Facility/Owner Name Facility ID#(if applicable)
�+ �p ft. ft
q Q Z �
I /a'*S C_"Oss Vaa s c ' k ft. ft. `kj
Physical Ad C ,and Zip 21_REMARKS
r J
County Parcel Identification No.(PIN) j2rpnessinn Unit
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: ec i�n
(ifwe0 field,one lat/long is sufficient) 22.Certification: Doi f ii S� I,
SignatureWCertified Well Contractor Date
6.Is(are)the well(s): le1'ermanent or ❑Temporary By signing this form,I hereby certify that the wells)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 l�O 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 921 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: / 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 forme SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 1�O.S (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple weAs list all depths/fdifferent(example-3@200'and 22@11000) construction to the following:
10.Static water level below top of casing: eGV (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.Borehole diameter: 6.25 (in.) 24b.For Infection 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: /�O/'A �/ 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)_ l_s 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:
granular hypocholrite Amount: 140dewell construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013