GW1-2021-04452_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 DESCRIPTION
Well Contractor Name /0 ft. ft. 0 �1 a
2834-A ft. e.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a cable
FROM TO DIAMETER THICKNESS li ARTERIAL
Kennedy Well Drilling o ft. le ft. 6.25 SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(peothermal closed-loop)
�fC FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit tt:2OZO-0 0 DO 32 J ft. ft. in.
List all applicable well permits(i.e.County Siate,Mariance.Injection,etc.)
ft. ft. i in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. fL in.
❑Agricultural ❑Munici al/Public
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) tr. ft. fin•
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 fr. 20+ ft. Bentonite Hydrate chips in place
Nun-Wafer Supply Well:
ft. ft.
❑Monitoring ❑Recovery
injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
FROM TO MATERIAL EMPLACEMFr\`rMETHOD
❑Aquifer Storage and Recovers' ❑Salinity Barrier fr. ft.
❑Aquifer Test ❑Stormwater Drainage
fr. fr.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color.hardness,soillroch type,erain sim,etc.)
❑Geothenmal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) D ft. ft.
ft. o ft. y,
4.Date Well(s)Completed: Nell IDt/
ft. d ft. Ie � -_S
5a.Well Location: 90 R. ft.
/ ft. ft.
Faci
li
ty/Owner Jame Facility ID#(ifapplicable) ft. ft.
ft. ft.
Physical Addr ,City.and Zip 21.REMARKS
nunit
77fY!�f5g_ G ssin9
County f Parcel Identification No.(PiN) I11110f 13 $e , 11
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if wetl field,one tatllong is sufficient)
N w tL'3 l
Signatureertified Well Contractor Date
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6.is(are)the w•ell(s): ermanent or ❑Temporary By signing this fnrn;I hereby cerit/y that the it e//(.$)was(were)constructed in accordance
With 15A NCAC 01C.0100 of 15A ArCAC 02C.0100 Well Construction Smndardr and that a
7.Is this a repair to an existing well: ❑Yes or QiV0 cope,of this record has been provided to the well mt ner.
I/'this is a repair.fill nett known well con.struclion in1britunion and explain the nature aJ the
repair under=21 remarks section or on rite back Q/'thisJorm. 23.Site diagram or additional well details:
a You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: t construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY wish the same construction,you can
// SUBMITTAL INSTUCTIONS
submit one form.
9.Total well depth below land surface: Zeds (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For tuidtiple wells lisi all depths if dii ereiii(example-3@200'and 2@100') construction to the follo-tving:
10.Static water level below top of casing: (ft.)
Division of Water Resources,'Information Processing Unit,
I/crater level is obore casing,use''--" 1617 Mail Service'Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Infection Wells ONLY:I In addition to sending the form to the address in
24a above, also submit a copy of ithis 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 ofWater Resources,'Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield m rl Method of test: Air 24c.For Water Supply&injection Wells:
(gP ) Also submit one copy of this form within 30 days of completion of
Granular Hypochlonte well construction to the county health department of the county where
13b.Disinfection type: Amount: ��a6
constructed. t ;
Form GNYt-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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