GW1-2021-04238_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 i
1.Well Contractor Information:
Bill Kennedy 14.WATER ZONES
y y FROM TO DESCRIPTION
Well Contractor Nanie ft. .2. ft. 1
2834-A ft. age) fL ry.
NC Well Contractor Certification Number IS.OUTER CASING for mul d wells OR LINER if a ticsble
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling fr. ft. 16.25 '- 1 SDR-21 I PVC
Company Name 16,INNER CASING OR TUBING(geothermal dosed-loop)
_�^^�-f_��/ FROM TO DIAMETER THICKNESS MATERIAL
2.Weil Construction Permit#: _}10 /�/ (�9 -/ fr. ft. ln•
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft. im
3.Well Ilse(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE I THIC"FSS__J MATERIAL
❑Agricultural ❑Municipal/Pubiic ft. ft. in.
ft. ft. in.
❑Geothermal(Heating/Cooling Supply) PIRsidential Water SuPP1Y(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
[Irrigation 0 rr. 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 fr. fr.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color hardness soiuroch type,amin six etc.
OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 10
ft• ft. it
4.Date Well(s)Completed:V /! J-1 Well ID# tL 34 ft. Af. Vi
3® tr. fr. �1G1i1�5 n-G
5a.Well Location: h. 30,5—` 1 Kid 6 /'CPC-k
Ai• 1 L U L -55 Cen. ft. ft.
Facility/Owner Nanal Facility ID#(if applicable)
ft. 2 _
Physical Address,C'v,and Zip 21.REMARKS
AAPR 9 2021
County Parcel identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: `r t.v i C r sy,�,
(ifwell field,one latAong is sufficient) �:�y j?'"^•i3Oi 1
N W 44 -
�� Signatur Certified Well Contracto Date
6.Is(are)the well(s): EPermanent or OTemporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 01C.0100 or lSA NCAC 02C.0200 Well Construction Smndords and that a
7.Is this a repair to an existing well: ❑Yes or 21 ro copy of this record has been provided to the well owner.
If this is a repair,fill out knoivn well construction information and explain the nature of the
repair under"21 remarks section or on the back of this forni. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or.veil
8.Number of wells constructed: 1 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: 3 D-.'r (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdt,Oerent(eraniple-3(a 200'and 2@100') construction to the following:
,r
10.Static water level below top of using: r (ft) Division of Water Resources,information Processing Unit,
lfwaierlevel 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
(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.1'ield(gpm) Method of test:
Alf 24c.For Water Supply&injection Wells:
Also submit one copy of this form within 30 days of completion of
131b.Disinfection type: Amount: �
Granular Hypochlonte well construction to the county health department of the county where
��
constructed. f{
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Watcr Resources Re%ised August 2013
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