GW1-2021-04334_Well Construction - GW1_20210805

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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:
Billy Kennedy 14.WATER ZONES
FROM TO DESCRIPTTON.
Well Contractor Name ft. gv ft
2834-A 1.215�'t' Q& ft.
NC Well Contractor Certification Number 15.OUTER CASING for mul' wells OR LAVER ita cable
FROM TO INAMETER THICIINFSS MATERIAL
Kennedy Well Drilling It- a, n 6.25 itik5DIL-li(I AICI
Company Name 16.INNER CASING OR TUBING(geothermal closed-loopl
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft ft. in.
Gist 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 THICNNESS MATERIAL
ft rL in.
❑Agricultural ❑M�unicipal/Public
❑Geothermal(Heating/Cooling Supply) Ofesidential Water Supply(single) 18. ft ft to
❑Industrial/Commercial ❑Residential Water Supply(shared) FROM
FOM TO MATERIAL EMPLACEMENT METHOD!a AMOUNT
❑Itri ation ft. it• Bentonite. Hydrate chips in place
Non-Water Supply Well:
ft ft.
❑Monitoring ❑Recovery
Injection Well:
❑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 pi.
TO DESCRIPTION color,hardness,saturock in sine etc
❑Geothermal(Heating/CoolingReturn ❑Other(explain under#21 Remarks4.Date Wells)Completed: -/� 61brai do
-al Well ID# ft
5a.Well Location: ft.
A Ke h G�Gt r.�G ft. ft
Facility/Owner Name Facility ID#(ifapplicable) ft ft
7X<0,3 5J `
`+���/ r Tom-/ Kef ft ft �' 2
Physical Address,City,and Zip 21.REMARKS
c.I.,ad��-i asy o�ss
County Parcel Identification No.(PIN) 1n�0(((: R S@G
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one Iattlong is sufficient)
N w
� Signature o tified Well Contractor Date
6.Is(are)the weU(s): 21'ermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
7.IS this a repair to an existing well: ❑Yes or 21< 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 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
S.Number of wells constructed'_ construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONI Y with he same construction,you can
submit one form. Q' SUBMITTAL INSTUCTIONS
9.Total well depth below land surface:�`tt� (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiQerent(example-3(200'and 2@100) construction to the following:
10.Static water level below top of casing: 16 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Iniection Wells ONLY:i'In addition to sending the form to the address in
24aabove, also submit a copy of!this form within 30 days of completion of well
12.Well construction method: An+* arQ 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
24c.For Water Water Supply Injection Wells:
Wells:
13a.Yield(gpm)�� Method of test:��tr 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:���� ; I
constructed.
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Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources : Revised August 2013
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