GW1-2021-03787_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 i
1.Well Contractor Information:
Billy Kennedy ry'� n Fx MATER ZONES TO DESCRIPTION
Well Contractor Name ° ft. ft. t /M
2834-A S tP ,n 2021 a ft. A GlJ ft. SX
15.NC Well Contractor Certification Number FROOjytUTER CASING
G �r m DIAMETEReIIsul O If a Iica�ble)
�•r.
Kennedy Well Drilling II1i�rr.'�n�VR �. r�on ft. ft. 6.25 SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
Q 003.S � FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft ft. in.
List all applicable well permits ri.e.County,State,Variance,Injection,etc.)
Yt. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM . TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft ft in.
❑Agricultural ❑M�unicipaVPublic
❑Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) ft ft to
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri 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 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,hardness soiUrock type,grain dw,etc.
❑Geothermal eating/Cooling Return) ❑Other(ex lain under 421 Remarks) A ft. e2 ft A
�1 ft, ft. d
4.Date Well(s)Completed: �[ ell ID# k. 36S% `O
5a.Well Location: ft. ft.
S te,(>-/7 ;lid a is ft. ft
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
19W P TRI- ft ft
Physical Address, ity,and Zip 21.REMARKS
ti 2 24A/2'79 73 k
County ParcelIdentification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
� • Signature fled Well Contractor Date
6.Is(are)the well(s): [?Permanent or ❑Temporary By signing this form,I hereby certify that the wells)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 eidsting well: ❑Yes or QNo copy of this record has been provided to the well owner.
IJ'this is a repair,fill out known well construction information and explain the nature ofthe
repair under#21 remarks section or on the back of this farm. 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
For multiple wells list all depths if&ferent(example-3 a200'and 2Q100� construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 276994617
11.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 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:
U Also submit one copy of this form within 30 days of completion of
Granular Hypochiorite 1 D S well construction to the county health department of the county where
lab Disinfection type: Amount: Z
constructed.
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Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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