GW1-2021-03791_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: i v
¢>�:,9 <'n 14.WATER ZONES
Billy Kennedy P �: FROM TO oESCRB'TION
Well Contractor Nameft. Sd fr.
a n 6
2834-A StP 1'` 2 t�rz>� es ft.
°'('•'� 15.OUTER CASING for mul sed wells OR LINER if a Iicahle
NC Well Contractor Certification Number
�'�y-' •r 1� FROM TO DIAMETER MEDCKNFSS MATERIAL
Kennedy Well Drilling �c+��Ee� �@,u�'�"� ft. 3 Ll ft 16.25 i° SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: t��(` /J f���� N 7 ft. ft. in.
List all applicable well permits(i.e.County,Slate,Variance,Injection,etc.)
ft. ft. ' hL
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO J.DIAMETER I SLOT SIZE I THICKNESS MATERIAL
ft ft in.
❑Agricultural ❑M�unicipal/Public
El Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) ft ft. iu
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 fa 20+ fl• 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 a licable
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 DES ON color,hardness soil/rock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. ft. ..7 gL ft. 1 ft. Q�•f9W� a _
4.Date Well(s)Completed: Well ID#
Q5w ft. 2�lW ft. !
5--a..Well Location: ft. ft.
J0/\fA�s[fV �f'I[ ft. ft.
Facility/Owner Name Facility lD#(if a plicable)
-� �/� / T `�1 ft. ft.
/�I/ hP,�/��S / �� QS /` ft. ft.
Physical Addres City,and Zip 21.REMARKS
County Parcel I entification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one]at/long is sufficient)
N W J,& `aoa
Signaturc&f Certified Well ContractorCJ Date
6.Is(are)the well(s): O ermanent or ❑Temporary By signing this form,I hereby certify thai the 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 25o copy ofthis record has been provided to Ole 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
S.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLk with the same construction,you can
submit one farm. ^^ SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: O Jr (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@I001 construction to the following:
10.Static water level below top of casing: 3 (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
't
11.Borehole diameter:
6.25 (in.) 24b.For Iniection Wells ONLY: In 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(gp m) / Method of test: Air 24c.For Water Supply&Injection;Wells:
Also submit one copy of this form within 30 days of completion of
Granular Hypochlodte well construction to the county health department of the county where
.13b.Disinfection type: Amount: bra—x constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013