GW1-2021-03789_Well Construction - GW1_20210903

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WELL CONSTRUCTION RECORD For Internal Use ONLY: f
This form can be used for single or multiple wells
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1.Well Contractor Information:
�,p 7r 14.WATER ZONES
Billy Kennedy �-.+•;tom�_m+a.Y ;,x� FROM TO DESCRIPTION
Well Contractor Name G0 & D o ft. '
2834-A �� 2p21 Oft. if r� ft. I 'm
S C 1 15.OUTER CASING for mul ed'wells OR LINER if a licable
NC Well Contractor Certification Number t�IZI FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling � , Cl a:wn` �.n;lo� fr. ft 6.25 '" SDR-21 PVC r
Company Name 16.INNER CASING OR TUBING eothermrd closed-loo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: � -DODD a3/7 fL 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 THICKNESS MATERIAL
ft. ft in.
❑Agricultural ❑Municipal/Public
ft. ft: in.
❑Geothermal(Heating/Cooling Supply) esidentiai Water Supply(single)
❑Industrial/Commercial ❑Residential Water Suppiv(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ff. 20+ ft. Bentonite Hydrate chips in place
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery
fr. fr.
Injection Well:
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVEL PACK ifa licable
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft.
❑Aquifer Test ❑Stormwater Drainage fr. ft.
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❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION tutor,hardness,suit/rock PiM ori.sim,art.
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) It. ft. &W clay
fr. ft. _S
4.Date Well(s)Completed:= We11 iD# ft• ft.
5a.Well Location: It. nCfr. b �pr�L
ft
u�� �o�✓ ft.
Facility/Owner Name Facility iD#(if applicable)
-01a 1.7 du;(, u y ft. ft.
Physical Addr ,,Ci ,and Zip 21.REMARKS
County
Parcel n No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
N W
/ Signature ertified WeII Contractor Date
6.is(are)the well(s): Q'Permanent or ❑Temporary By signing this form,I hereby cerif} that the well(s)was(iere)constructed in accordance
with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well- ❑Yes or 2<0 copy of this record has been provided fo the well owner.
If this is a repair,)ill 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 SUBMITTAL INSTUCTIONS'
submit one form. A �
9.Total well depth below land surface gs (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
!br multiple wells list ail depths ifuli erent(example-3@200'and 2 ter 100') construction to the following:
10.Static water level below top of casing: f� (ft.) Division of Water Resources,'Information Processing Unit,
Ifsvater level is above casing,use"-" 1617 Mail Service Center,Raleigh,NC 27699-1617
IL Borehole diameter:
6.25 (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
Rota 24a above, also submit a copy Hof this form within 30 days of completion of well
12.Well construction method: Rotary construction to the following: i
(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
Granular Hypochlorite well construction to the county health department of the county where
13b.Disinfection type: Amount: a Q� constructed.
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Form Gil;-] North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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