GW1-2021-03351_Well Construction - GW1_20210419

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WELL CONSTRUCTION RECORD For Internal use ONLY:
This form can be used for single or multiple wells f
1.Well Contractor Information: '
Billy Kennedy 14.WATER ZONES
FROM TO I DESCRIPTION
Well Contractor Name fL is ft.
2834-A ft. f6
NC Wall Contractor Certification Number 15.OUTER CASING for molti-cased wells OR L R if a livable
FROM TO DIAMETER THICIQVESS MATERIAL
Kennedy Well Drilling ft c1 it 16.25 ,7Q- 1 G-�d
Company Name 16.INNER CASING OR T[JBING eothermal closed-l000l
�D FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ff• ff in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ff. ff. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE T.Cl(NEss MATERIAL
ft. ff. is
❑Agricultural ❑M cipaI/Public
❑Geothermal(Heating/Cooling Supply) QResidential Water Supply(single) ft. IL
in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri ation t9 ft. Bentonite Hydrate chips in place
Non-Water Supply Well:
K ff.
❑Monitoring ❑Recovery
Injection Well: ft; ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ff,
❑Aquifer Test ❑Stormwater Drainage
ft. ff. ,
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if moss
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION mler,hardness sail/rack type,Erain situ etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ff' 3 ft. w - e4 if G In v
3-Qq D 1 ff. /-ft. �L
4.Date Well(s)Completed: Well ID# ff J f
5a.Well Location: ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
yD Lo /t�Ct e 4 led ft ft. 021
Physical Address,City,and Zip-' 21.REMARKS '
County Parcel identification No.(PIN) Tit
5b.Latitude and Longitude in degreeshninutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
N w 611a y aDa I
f�' Signa Certified Well Contractor Date
6.Is(are)the well(s): Wermanent or ❑Temporary By signing this form,1 hereby centfy that the well(s)was(were)constructed in accordance
�1�1� 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 Lt0 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 921 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: j construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construMlon,you can
submit one form. / SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: �S (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: =I (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
JJ 24a above, also submit a copy of this form'within 30 days of completion of well
12.Well construction method: l-Cr/ 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
13s.Yield(gpm)__ Method of test: l✓ �•For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: F IT ti Amount: ;: ee9c well construction to the county health department of the county where
constructed.
Form GW-i North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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