GW1-2021-03785_Well Construction - GW1_20210903

It
WELL CONSTRUCTION RECORD For Internal Use ONLY: f
This form can be used for single or multiple wells
1.Well Contractor Information:
�* 14.WATER ZONES
Billy Kennedy
R1. FROM TO DESCRIPTION
Well Contractor Name Z yp G ft I Pr ft
-30
2834-A ft. ft
NC Well Contractor Certification Number S t 1 J 2021 15.OUTER CASING for multi cased wells OR LINER if a licable
tJ 1Z� FROM TO DIAMETER THICKNFSS MATERIAL
Kennedy Well Drilling r,(a��•'s. J ft ae it 6.25 SDR-21 PVC
. _1,. 1tit1�
Company Name „F4' p` ar' !13f- 16.INNER CASING OR T[TBING(geothermal closed-loop)
NR�-�
^ FROM TO DIA
METER THICKNESS MATERIAL
2.Well Construction Permit#: o W 1013 y" D ft ft• Al in' ?v
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: THICKNESS MATERIAL
h. ft in•
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) tliMesidential Water Supply(single) ft it in
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
9__"
TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑1ri ation 20+ ft Bentonite Hydrate chips in place
Non-Water Supply Well:
O ft
❑Monitoring ❑Recovery
Injection Well: ft.
❑Aquifer Recharge ❑Groundwater Remediation . RAVEL PACK if applicable)
FROM TO I 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 I TO DESCRREP ON color,hardness sommck qW,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 4121 Remarks) ft ft.
ft O ft.
4.Date Well(s)Completes_ '�'� ( Well ID#
O ft S" r lie-
5a.Well Location: ((�� ft. ft.
's ws'A /1���5 ft. ft.
Facility/Owner Name Facility III#(if applicable)
ft. ft
TbD �k�,�u,L_.n�e c Rol ft ft
Physical Address,City,and Zip 21.REMARKS
/106411tQ42 :f
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) A1 �^
� Signatm f CertifiTet{Well Contractor Date
6.Is(are)the well(s): ie<.-anent 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 BNo copy ofthis 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 ofthisform. 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: ��J (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
Far multiple wells list all depths ifd*reni(example-3Q100'and2@11001 construction to the following:
10.Static water level below top of casing: 70 00 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: I Tn'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.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 30 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 Hypochlorite Amount: well construction to the county health department of the county where
�DZ
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
1