GW1-2021-00060_Well Construction - GW1_20211109

WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information:
BIII Kenner 14.WATER ZONES
Y y FROM TO DESCRIPTION
Well Contractor Name Oft ft. 1 I
2834-A
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a likable
FROM TO DIAMETER TAICKNFSS MATERIAL
Kennedy Well Drilling 67 ft. eZl fL 16.25 i" SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: .3 fe(/S�3 ft I. 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 S12E THICKNESS MATERIAL
❑Agricultural ❑M�uni-cipal/Public ft• ft. in.
❑Geothermal(Heating/Cooling Supply) 01C.idential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 IL 20+ IL Bentonite Hydrate chips in place
Non-Water Supply Well: ft ft
❑Monitoring ❑Recovery
Injection Well: rr tt.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stonnwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness sollimck type,grain silo eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft. �/
ej
ft. 6 j
4.Date Well(s)Completed: !D'o�-a�Well ID#
ft. ft.
5a.Well Location: ft. ft.
)SrgArjeyn 6/Owpi fL ft.
Facility/Owner Name Facility ID#(if applicable) �y
l4 61 ,.�1�14 J rL rL P
Physical Address,City,and Zip 21.REMARKS NOV 2nqJ
Foote, f?G12n�as-G
County Parcel Identification No.(PIN) t k SECTION
ORMOMPROCESSING
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: UNI I
(ifwell field,one IaUlong is sufficient) D
N W
Signature Certified Well Contmcto Date
6.Is(are)the well(s): 2fermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or Jl copy of this record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of 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-water supply wells ONLY with the same construction•you can
submit one form. // SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 4 ��7� (ft.) 24a. For All Wells: Submit this,form within 30 days of completion of well
For multiple wells list all depths ifdderent(example-3@200 and 2@100) construction to the following:
10.Static water level below top of casing: 30 (ft) Division of Water Resources,Information Processing Unit,
1f water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
II.Borehole diameter 6.25 (in.) 24b.For Infection Wells ONLY: i 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,iUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) oL Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type:
Granular Hypochlorite Amount: DL
�i well construction to the county health department of the county where
�O
constructed.
Forth GW-I North Carolina Department of Environment and Natural Resources-Division of Water kesources Revised August 2013
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