GW1-2021-01820_Well Construction - GW1_20210419

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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:
Ei### Kenned 14,WATER ZONES
Y Y FROM To DESCRIPTION
Wall Contractor Name ft. �O tt
2834-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drifting 0 ft ft. 6.25 In. SDR-21 I PVC
Company Nano 16.INNER CASING OR TUBING tgeothermal closed-loo
FROM I TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft in.
3.well Ilse(check well use): 17 SCREEN
Water Supply well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural 0,Mu��nicipai1public ft o R. t
❑Geothermal(Heating/Cooling Supply) .BResidential Water Supply(single) ft ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
171rr; ation 0 ft' 20+ ft- Bentonite Hydrate chips in place
Non-Water Supply Well:
OMonitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
OAquifer Recharge OGroundivater Remediation 19,SAND/GRAVEL PACK ifs livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO
ft. ft. MATERIAL I EMPLACEMENT METHOD
LAquifer Test ❑Stormwater Drainage
ft . #r.
OExperimental Technology ❑Subsidence Control
20.DRILLING LOG lattach additional sheets if necessary)
OGeothermal(Closed Loop) OTracer FROM TO DESCRIPTION color,hardness soil/rock tym train sim etc.
❑Geothermal (Heating/Cooling Return) 170ther(explain under#21 Remarks) 0 ft. 3 ft. e �Gs
1 ft. fir— ft. r�tLlr1
4.Date lVell(s)Completed: 3-3va�f Well ID#
39— ft. •11 ft.
5a,Well Location: 4`
/t ft. s-- ft.
&an Ere We r ft. ft.
FaciiitylOwner Name Facility ID#(ifapplicable)
+� ,r1 � / , ft. ft
cT ta0/7[ f�t�(_ L,d t, r. ft. ft
Physical Address,City,and Zip
/f 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 & &,". - 3
Signature oohrtified Well Contractor Date
6.Is(are)the well(s): 0fermument or OTemparary By signing this form.I hereby certify that the well&)was(mere)constructed in accordance
with iSA NCAC 02C.0/00 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: OYes or tal'do'^ copy of this record has been provided to the well owner.
If thts is a repair.Jilt out known reel!construction tnformatton and explain the mature oj'the
repair under"21 remarks section or on the back of this firm, 23.Site diagram or additional well details:
/ You may use the hack of this page to provide additional well site details or well
S.Number of wells constructed: ! construction details. You may also attach additional pages if necessary.
For multiple injection or non-waler supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: .� {ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths lfdiffiirent(example-3@200'and 2@100') construction to the following:
+
10.Static water level below top of casing: r (ft,) Division of Water Resources,Information Processing Unit,
If water level is above casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.Borehole diameter: 6.25 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
Rotary 24a above, also submit a copy of this fbtm 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
Granular Hypochlorite well construction to the county health department of the county where
13b.Disinfection type: Amount: fl d constructed, '
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Form G W-t North Carolina Department ofEnviranmcnt and Natural Resources-Division of Water Resources Revised August 2013