GW1-2021-00072_Well Construction - GW1_20211109

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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:
14.WATERZONES
Billy Kennedy
FROM TO DESCRIPTION
Well Contractor Name S/ft. SD R.
2834-A erS-R. 0 rt. .3 M
NC Well Contractor Certification Number 15.OUTER CASING for multi-eas wells OR L[NER if a livable
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling ft. 01 ft. 6.25 in. I SDR-21 PVC
Company Name 16.INNER CASING OR TUBING eothermal dosed-loop)
^/�^ ��77 �/••►► pry� FROM TO DIAMETER THICKNESS MATERIAL
1.Well Construction Permit#: 'Q02I 0_0001D�I R. ft in.
List all applicable well permits(i.e.County,State,Variance.Injection,etc.)
ft. ft. im
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO I DIAMETER I SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. R. in.
❑Geothermal(Heating/Cooling Supply) 21residential Water Supply(single)
ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 It. 20+ ft• Bentonite Hydrate chips in place
Non-Water Supply Well:
rt. rL
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifapplicable)
PROM I TO I MATERIAL EMPLACEMENTMLTHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soiltmk type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) O ft.
a
ft. O ft. la 4I
4,Date Well(s)Completed: Well ID# _
5a.Well Location: rt. AO ft. geft. ArR.
AJ//��f rt9G1jL
J60est-5s COh ft. rt.
Fi cilityi0wrick Name Facility ID#(if applicable) ft. ft.
_Il 7Y A'a 1/i J,P.yt c 2. tJ,u�Gli R. ft.
Physical Ad City,and Zip 21.REMARKS
7�'77306412 9202,
County Parccl Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: t OWN5 PION
(if well field;one lat/long is sufficient) INFORMATION PROCESSING UNIT
N W /L�1Q/ �` a- /A-X-2/
/ Signature ertified Well Contractor Date
6.is(are)the well(s): 0Permanent or ❑Temporary By signing this form,I hereby certify that the i ell(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 0% copy of this record has been provided to the well owner.
If this is a repair,fill out knonn well construction information and explain the nature of the
repair under#21 remarks section or on the back of this farm. 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: r 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 oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: tD47 (ft.) 249. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 1@100') construction to the following:
10.Static water level below top of casing: 3.5- (ft.) Division of Water Resources,Information Processing Unit,
If wane,•level is above casing,use '+' 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.Borehole diameter: 6.25 (in.) 246.For Infection Weill 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.) l
Division ofWater 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) 11 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 Hypochlodte Amount: / well construction to the county health department of the county where
Cis= ;
constructed.
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Form GW-I North Carolina Department of Environment and Natural Resources-Division of Waier Resources Revised August 2013
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