GW1-2021-05824_Well Construction - GW1_20210709

WELL CONSTRUCTION RECORD 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
0 ft o ft.
2834-A .1yo ft a5(S''t
NC Well Contractor Certification Number 15.OUTER CASING for mul wells OR I.DVER if a lieable
FROM To DIAMETER THIQ4VESS MATERIAL
Kennedy Well Drilling Q It. 33 ft 16.25 1n 1 SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING leeothermal dosed-loo
t�—� FROM TO DIAMETER THICINESS MATERIAL
2.Well Construction Permit#: 55 3 /o ft & . m.
List all applicable well permits 0.e.County,State,Variance,Infection,etc.) iL ft in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT Sr M THICtavESS MATERIAL
❑Agricultural ' ❑Municipal/Public ft ft io..
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) R' R m
❑lndustriaUCommercial ❑Residential Water Supply(shared) I&GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑ltri ation 0 ft' 20+ ft. Bentonite Hydrate chips in place
Non-Water Supply Well: it ft
❑Monitoring ❑Recovery
Injection Well: f ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
FROM I TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier fr &
❑Aquifer Test ❑Stormwater Drainage
rt tt ,
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necesm
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hotness,adUroch n dy,etc.
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks • ft• a ft Q
ft ft
4.Date Well(s)Completed: G `30 �cll ID# H
Sa.Well Location: % ft
ASlh a \r1 ft ft
Facifity/Owner Name Facility ID#(if applicable) ft ft
H b Sa-wn 1\ Lan(?- &nbins ar7-:W fL fL
Physical Address,City,and Zip 21 REMARKS
Mao o oo 1 a co 1 q Inform. 'a C ct9on
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 ZIS 6-30 Q0.2
Signoz&fCcrtified Well Contract Date
6.Is(are)the well(s):'P34rmanent or OTemporary By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
with 1 SA NCAC 02C.0100 or ISA NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or )260 copy ofthis record has been provided to sire 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: 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. / SUBMITTAL INSTUCTIONS
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 tfdifferent(example-3Q200'and 2@10,01 construction to the following:
10.Static water level below top of casing: �iJ 01.) Division of Water Resources,Information Processing Unit,
Ifrvater 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
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.) 1
Division of Water Resources,!Uoderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) �s Method of test:
Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this forin within 30 days of completion of
13b.Disinfection type: Granular Hypochlonta Amount: well construction to the county health department of the county where
constructed.
1
Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
I