GW1-2021-04610_Well Construction - GW1_20210510

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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: ski t
Billy Kennedy 3b'' .14.OM WATER ZONESFR TO DESCRIPTION;
Well Contractor Name 1 aY g ft �f ft.
v w
-" ft ft
2834-A
LC5S111�)U'n
II IfivCl'f+3=vT1 is.OUTER CASING for multi cased wells OR LINER if a licable
NC Well Contractor Certification Number p�v V j �^'[;�I� FROM TO DIAMETER TIDCKNESS MATERIAL.
Kennedy Well Drilling & b(0 fz s.25 'ti I SOS-a1 I
Company Name 16.INNER CASING OR TUBING eodwrtnal dosed400
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ao 00000 C�o ft ft is
List all applicable well permits.fl.e.County,State,Variance,Injection•etc.)
ft. ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER -SLAT SIZE THICKNESS MATERIAL
fL ft is
❑Agricultural ❑Mumicipal/Public
❑Geothermal(Heating/Cooling Supply) (�ential Water Supply(single) ft ft 'm
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
01ni lion O rt ap ft- Bentonite Hydrate chips in place
Non-Water Supply Well: & ft
❑Monitoring ❑Recovery
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a icable
FROM TO MATFRtAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft
❑Aquifer Test ❑Stormwater Drainage t ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necess
❑Geothermal(Closed Loop) ❑Tracer FROM TO D ON color,hardnev6 soiurock tym own,shb,etc.
❑Geothermal(Heating/Coolin marks Return) ❑Other explain under 421 Re ft. & eQ GL
4.Date Well(s)Completed: Well ID# S fr, p10 ft G/
vO�ll ft ft {
5a.Well Location:
PA.') Pc�rA�ss ft ��-f a� �
Facility/Owner Name Facility ID#(if applicable)
// IL
ft ft
_ 3l�� &ro e1�,'1A L 1� f ft ft
Physical Address,City,and Zip 21.REMARKS
4 7669�fts��7�
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degreeshninutes/seconds or decimal degrees: 22.Certification:
(if well field,one IaUlong is sufficient)
N W 6d
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Signa a fCertified Well Contractor Date
6.Is(are)the weil(s): RKrmanent or ❑Temporary By signing this form,1 hereby certify that the well(s)was(were)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 2No 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 ofthisform. 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: I 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 INSTUCfIONS
9.Total weII depth below land surface: zd-,r (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths indifferent(example-3(200'and 2@100) construction to the following:
10.Static water level below top of casing: 30 (tt.) 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
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: A t construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPL,Y�WELLS ONLY: A 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) oC7 Method of test: /f r 24c.For Water Supply&Injection Wells:
Also submit one copy of this form;within 30 days of completion of
131L Disinfection type: HTH Amount: well construction to the county health department of the county where
constructed.
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Farm GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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