GW1-2021-05537_Well Construction - GW1_20211013

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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: 5N k
Billy Kennedy 14.WATER ZONES
t nk FROM TO DESCRIPTION
Well Contractor Name R 170 ft. ft I
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2834-A �C �e�sm9� ft, ft.
I Q', 15.OUTER CASING for multi cased wells OR LINER if a ticable
NC Well Contractor Certification Number``tf�tC,v,,a€;Q�n 5�Ct\OO FROM TO DIAMETER TfDCIINRSS MATERIAL
Kennedy Well Drilling 1 0 S� ft. ,Sa ft 16.25 SDR-21 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: WQ! DD(.(//!/�f� ft ft in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc)
ft. ff. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft ft in.
❑Agricultural ❑�Municipal/Public
❑Geothermal(Heating/Cooling Supply) lj�Residential Water Supply(single) ft ft. in
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft' 20+ rL 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 applicable)
FROM TO MATERIAL I 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 I TO DESCRIPTION color,hardness soil/rock type,grain dze,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. ft 1
II ft ft d „
4.Date Well(s)Completed: �!G—�' Well ID# ft. ft.
!OG
Saa.Wellll Location: t
ft. f
Cell/ 6a S ff. ft
Facility/O ter Name Facility ID#(if applicable)
ft. ft
7,30 C�r rC ft. ft
Physical Address,City,and Zip J 21.REMARKS
/lartole%eG. 7 953�Z2/4
County Pacel r Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
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Signat&4&Cerfificd Well Contractor - ' Date
6.Is(are)the well(s):Xrmanent or ❑Temporary By signing this form,I hereby certify that the well(s)was'(rvere)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 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
S.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 construction,you can
submit one form. / SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: aaa7 (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 �� (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 Infection 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(gpm) Method of test:
Air 24c.For Water Supply&Injection'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
lab Disinfection type: Amount: /�Ate— constructed. I
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Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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