GW1-2021-04613_Well Construction - GW1_20210510

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iRr�1 T !`l1NCTDiT!`TTl�lii A1G•("(_lAil �
ror mtemai use UNLY:
This form can be used for single or multiple wells V N'J 7 ,
1.Well Contractor Information: 3� ddtt
Rilhi Kannarly 14.WATER ZONES
r 'J �V 'tl i� 22� rnum to uwLn�r sun
Well Contractor Name j--� O ft. ft
nrOSSing Ut111
2834-A „3;;�p P[• e. ft.
NC wcii wuiiadu,Cdiiu ai vo i:wuuca Ir1 v u J��" I C)n 15.OiJTER CACtNG Ifnr multi-cased we11n10R LINER fifannlicablel
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling ft. ft. 16.25 In
C,
Company Name 16.INNER CASING OR TUBING eothermal dosed-too
FROM TO DIAMETER THICKNESS I MATERIAL
2.Well Construction Permit#: �cXV`�J 6�trCt/�:�/y�= - & tt in.
List all applicable upell permits(i.e.County,State,Variance,Injection,etc•.J
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
'Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
f1 ft. in.
OAgricuitura) ❑MunicipaVPublic
❑Geothermal(Heating/Cooling Supply) RR'e'sidential Water Supply(single)
ft ft. is
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 ft' 20+ It- Bentonite Hydrate chips in place
Non-Water Supply Welk
ft. fr.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
OAquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK if a licable
FROM TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier fr. It.
❑Aquifer Test ❑Stormwater Drainage
ft. fr.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hartIness.soil/rock type,grain site etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0
fit. ft.
4.Date Welts)Completed: - Well iD# fr. ft. w/1
70 ft. ft. !oG
5a.Well Location: ft. ft.
'6ri0 ii"t �7 r2>°N tr. ft.
Facility
r/ J�
/Owner Name Facility
/ Facility ID#(if applicable) ft. ft.
& o/ r N /// �Z', ft. ft.
e
Physical Addre s,City and Zip 21.REMARKS
,trio/,o ti13
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one latnong is sufficient) a �/
N w
_�� Signatur o ertified Well Contractor Date
6.Is(are)the well(s): iJPermanent or ❑Temporary by signing this form,I hereby certify that the wells)was(were)consattcted in accordance
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with 15A NCAC 01C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or D140 copy of this record has been provided to the well owner.
/J'this is a repair,Jill out known well construction information:and explain the nature of the
repair under 11 remarks section or on the hack of this fornn. 23.Site diagram 0r 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 Lorin. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: J� (ft.) 24a. For All Welts: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiffereni(example-3@200'and 1@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Iniection Welts 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: 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 hypocholrite well construction to the county health department of the county where
13b.Disinfection type: Amount: 07
constructed. } j
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013