GW1-2021-04456_Well Construction - GW1_20210805

I
WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.Billy Kennedy FROM ZONES DESCRIPTION,
Well Contractor Name 3 ft. &
i
2834-A .S fL
NC Well Contractor Certification Number 15.OUTER CASING for mnl wells OR LAVER if livable
FROM TO DIAMETER THIt:fUVESS MATERIAL
Kennedy Well Drilling 0 It. oZ 8 iL 6.25 Ia SDR-21 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed4cioul
`- `�„�^ L� FROM TO DIAMETER: THI(IINFSS MATERIAL
2.Well Construction Permit#: � C6yesN/L/t��� ` IL ft DIAMETER
List all applicable well permits ri.e.County,State,Variance,Injection,etc.)
fL ft. in
3.Well Use(check well use): 17.SCREEN
Water,Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in
❑Geothermal(Heating/Cooling Supply) Beesidential Water Supply(single) R' D" in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
❑Im ation 0 fL 20+ D• Bentonite Hydrate chips in place
Non-Water Supply Well:
R ft
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. Ill.To MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
& ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG fattach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,sattirodr IM Valn simp,etc.
❑Geothermal eatin Coolin Return ❑Other(explain under#21 Remarks Q n• - ft.
4.Date Well(s)Completed: -&-a I Well ID# a fL .1-
ao fc t2�'fL
5a.Well Location: ft ft
Arc v ljll�**e-S tL ft.
Facility/Owntr Name Facility ID#(if applicable)
ft. ft
,3@Eq L_t'-ff)ro s 4r f. ft. 5 2
Physical Address,qity,and Zip 21.REMARKS
�1�`e ll on prOt essln
County Parcel Identification No.(PIN) WYK beUllul,
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one tattlong is sufficient) D f
N W
Sign Certified Well Contractor Date
6.LR(are)the well(s): We-rmanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
_� with ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
F1 7.Is this a repair to an existing well: Dyes or No copy of this 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
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 construcdait,you can
submit one form SUBMITTAL INSTUCI'IONS
9.Total well depth below land surface: OYES (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths tfdii erem(example-3@200'and 2@I001 construction to the following:
10.Static water level below top of casing: (ft.)
�!�I Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Matz Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b For Infection Wells ONLY: Inladdition to sending the form to the address in
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 Cent i r,Raleigh,NC 27699-1636
13a.Yield(gpm)!��_ Method of test: Air 24c.For Water Supply&Infection Wells:
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:
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013