GW1-2021-03687_Well Construction - GW1_20210903

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bill Kennedy 14.WATER ZONES
Y y FROM TO DESCRIPTION
Well Contractor Name ft. ft
2834-A ft. &
NC Well Contractor Certification Number 15.OUTER CASING far multi cased wells OR LINER if a licahle
FROM TO DIAMETERTIDCKNESS MATERL L
Kennedy Well Drilling ft• 02 ft 6.25 SDR-21 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
FROM TO DIAMETER ' I THICKNESS MATERIAL
2.Well Construction Permit#: (/o ft ft. in
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft: ft. in-
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE. TMCK NESS I MATERIAL
ft fL in•
❑Agricultural ❑M pal/Public
❑Geothermal(Heating/Cooling Supply) OResidential Water Supply(single) ft ft in
❑Industrial/Commercial ❑Residential Water Supply(shared) 19.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑bTi ation 0 ft 20+ ft 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)
FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft. �
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardnras saillmek etc.
❑Geothermal(Heating/Cooling Return) ❑Other{explain under#21 Remarks) d ft- ft a
��
ft � ft.
4.Date Well(s)Completed:8_1t-,2 Well ID# t
ft ft `
5a.Well Location' ft. ft.
ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft.. ft. e e ice'
ft. ft
Physical Acd City,and Zi
21.REMARKS
a_• `G e / �L<<^'I U�] �oCO 33" 'trr r-� ittelj
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22,Certification:
(if well field,one tat/long is sufficient)
� Signatur Certified Well Contractor Date
6.IS(are)the well(s): QPermanent or ❑Temporary By signing this form,1 hereby certify iharthe well(s)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 allo 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: 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: (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfdifferent(example-3(a 200'and 2@1100) construction to the following:
10.Static water level below top of casing: 010 (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 On-) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
Rotary 24a above, also submit a copy of this form 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
136.Disinfection type:
Granular Hypochlorite Amount: well 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