GW1-2021-05544_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: ,
,►n
Billy Kennedy FR 1RwATERzoNEs ;.9
OM TO DESCRIPTION
Well Contractor Name 1 � 1 ft ft ['�
2834-A rCU Je�g�C�OJ 3�t. ei/p ft.
>1���0'� p(,\�O( 15.OUTER CASING for mnl' wells OR LINER if a ticable
NC Well Contractor Certification Number
�� FROM TO DIAMETER I CI THIOVFSS MATERIAL
Kennedy Well Drilling 0� 0 ft 1 3 1 ft 6.25 1 SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
�t ^7 FROM TO DIAMETER TfflCKNFSS MATERIAL.
2.Well Construction Permit#: 0 01 a/g 9 ft & in'List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft & in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Iri ation 0 It' 20+ ft 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 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 nccessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DFSCRIMON color,hardness soWrock PIM Zrain size,etc.
❑Geothermal(Heating/Cooling
Return) ❑Other(explain under#21 Remarks) 0 ft. S' ft• -. G G
4.Date Well(s)Completed: f -�/Well ID# ft ft 16roe N .�A
as I tt.
5a.Well Location: ft. ft.
JOGtepSs Coe, ft. ft.
Facility/Owner Nam Facility ID#(if applicable)
aa ft. ft.
0,P( LAI ft. ft.
Physical A City,and Zip 2l.REMARKS
4� /.o 1
County Parcel-I&mlfication No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one lat/long is sufficient)
N wAd
Signat4fSkfCertifiid Well Contract Date
6.Is(are)the well(s): ermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 99-. 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 ofthis 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 construction,you can
SUBMITTAL INSTUCTIONS
submit one form.
9.Total well depth below land surface: !(/ (ft.) 24a. For AO Wells: Submit this!form within 30 days of completion of well
For multiple wells list all depths rfdijferent(example-3Q200'and 2@1001 construction to the following:
10.Static water level below top of casing: oZ (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borebole diameter: 6.25 (in-) 24b.For Iniection 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) /00 Method of test: Alf 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
13h Disinfection type: Amount: d constructed. j
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Res iurces Revised August 2013
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