GW1-2021-05496_Well Construction - GW1_20211013

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WELL CONSTRUCTION RECORD Fur Internal Use ONLY:
This form can be used for single or multiple weld
1.Well Contractor Informatio 60�`
b `� i. yeti FROM
WATER ZONES
Billy Kennedy
FROM TO DESCRIPTION
Weil Contractor Name f°rP'�r�n- ft. t.
2834-A _ �,o�`A�A�,�� 0 ft. ft.
NC Well Contractor Certification NumA#t J 15.OUTER CASING for multi cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS 1ATERIAL
Kennedy Well Drilling a
fr. I t1l fr. 6.25 in SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-Itio
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: it'/s� fr. ft. is
List all applicable it perm Us 6 e.County.State,Varian inlecuun,etc'./
ft. ft. in.
3.Well Use(check well use): 17:SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
ft ft. in.
❑Agricultural ❑Mum�pallPublic
❑Geothermal(Heating/Cooling Supply) laResidential Water Supply(single) ft• ft. m
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft' 20+ ft- Bentonite Hydrate chips in place
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. fr.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
FROM I TO I MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG fattach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soil/rock tylse,gritin size,etc.
Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)j ft. ft. CL
ft. A/ ft. K
4.Date Well(s)Completed: ����'ell ID# � ft t—ft. � IL
5a.Nitellllll,Locatiio�n` 7/:J r�,� ,/� TI— ft ft.
e% � 4:% / E ,[ ft. ft
Facility/Owner Nam / / Facility iD#(ifapplicable)
A ft. ft.
?0 ord Alan k, /G/ ft ft
PhvsicaI Address,City,and Zip 21.RENIARKS
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one Iat/long is sufficient)
Signature q5Pertiflcd Well Contractor Date
6.Is(are)the well(s): WI;et manent or ❑Temporary, By signing this.torni,I hereby cerl f•that the irell(s)iras(here)constructed in accordance
irith 15A NCAC 01C.0100 or 15A AuCAC 02C.0200 Well Construction 5'tandardc and that a
7.is this a repair to an existing well: ❑Yes or [wo copy of this record has been provided to the well oirner.
,y this is a repair,till out known well construction information and explain the nature of the
repair under=21 remarks section or on the back oJ'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-trater supply iwells•ONLY irith the some construction,you can
submit one form. �f SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 1at� (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
par ttudtiple hells list all depths ifdifferent(example-3@200'and 2@l00') construction to the following:
10.Static water level below top of casing: f 2 (ft,) Division of Water Resources,Information Processing Unit,
//hater 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 `
Rotary 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ry 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.field(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
13b.Disinfection type: Amount:
constructed. I I
Form GW-I .North Carolina Department of Environment and Natural Resources-Division of Wateir Resources Revised August 2013
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