GW1-2021-00070_Well Construction - GW1_20211109

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
BIII Kennedy 14.WATER ZONES
Y y FROM TO DESCRIPTION
Well Contractor Name f7 ft. ft. M
2834-A ft. auto-ft.
M
NC Well Contractor Certification Number 15.OUTER CASING for mu sed wells OR LINER it a licable
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling 0ft. ft- 6.25 in. I SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
+� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#:;! _00�� fL ft. in.
List all applicable well permits ri.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. ft. in.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) RResr��en dtial Water Supply(single) ft. ft. in
❑Industrial/Commercial ❑Residential Water Supply(shared) ls.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 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 I 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 necessary)
❑Geothermal(Closed Loop) ❑Tracer rFROMTO DESCRIP N color hardo soil/rock a 'n sb etc.❑Geothermal eatin Cooling Return) ❑Other(ex lain under#21 RemarksfL Acel
4.Date Well(s)Completed: 0 A Well ID# Sb ft s�tt. t5a.Well Location: J a
A�/ is���
;I Eli t a e 55 Can . rL ft.
Facility/Owner Name Facility ID#(if applicable)
fL ft.
AR(aq 6x/'k#,_,, DR ft. rL
Physical Addps,City,and Zip
21.REMARKS
County Parcel Identification No.(PIN) IL
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5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
%�/�CQ
Signature ertified Well Contractor U Date
6.Is(are)the well(s): ermanent or ❑Temporary By signing this form,I hereby certify that the nell(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or- ❑No 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 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 farm. SUBMITTAL INSTUCTIONS
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9.Total well depth below land surface: (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3Q200'and 2@100) construction to the following:
10.Static water level below top of casing: A0 (rt.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 6.25 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
Rotary 24aabove, 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
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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
13b.Disinfection type:
Granular Hypochlorite Amount: /DG OZ
well construction to the county health department of the county where
constructed. rf
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Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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