GW1-2021-03786_Well Construction - GW1_20210903

WELL CONSTRUCTION RECORD
For Internal Use ONLY: �
This form can be used for single or multiple wells
1.Well Contractor Information: y�oo q
`i�-s c'�w 5 - 14.WATER ZONES
Billy Kennedy r_ a ,. FROM TO DESCRIPTION
Well Contractor Name
0 ft. 130 ft. t,+,
2834-A St� �n J ft. ft.
c; 5 r�lilll 15.OUTER CASING for multi-cased wells OR LINER if a licable
NCWeIIContractorCertificationNamber r,-nrA;.�.ft
�Od�r1-r�r„^�lj FROM TO DIAMETER! TEIICtINFSS MATERUIL
Kennedy Well Drilling 1 p��1R °''�1'0i' fL I d,$" rL 16.25 1 '- I SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
3 j n / FROM TO DIAMETER THICKNESS MATERIAL.
2.Well Construction Permit#: t� 7 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! SLOTSIZE TCIINESS MATERIAL
HI .
❑Agricultural ❑M�unicipal/Public tt ft. in.
❑Geothermal(Heating/Cooling Supply) 01R idential Water Supply(single) ft ft. in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrr; 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)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. TO ft. MATERIAL EMPLACEMENT METHOD
❑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,hardness soil/rack type,grain sae etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) it. � ft.
�1 ft ft
4.Date Well(s)Completed: Well ID#
5a.Well Location: ft. ft.
AQD �_ II �,/ /' ry- i
41,U /�'1 t/l�ICe �f�. ft. ft.
Facili�Owner Name Facility ID#(if applicable)
TB d 616 0-e e S All d c S(A'r. Ar` ft ft.
Physical Address,City,and Zip If
21.REMARKS
=00,19'3
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
SignatuE&Certificd Well Contractor Date
6.Is(are)the well(s): ❑Permanent or ❑Temporary By stgning this form,I hereby certify that the well(s)was(were)constructed in accordance
f 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 C31V0 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 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: I 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. �j SUBMITTAL INSTUCTIONS '
9.Total well depth below land surface: /IJ (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
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10.Static water level'below top of casing: 30 (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 (in.), 24b.For Infection Wells ONLY:! In addition to sending the form to the address in
Rotary 24aabove, 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
Air 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test: Also submit one copy of this form within 30 days of completion of
136.Disinfection e:
Granular Hypochlorite Amount: 5,67 well construction to the county health department of the county where
constructed.
b
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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