GW1-2021-00073_Well Construction - GW1_20211109

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WELL CONSTRUCTION RECORD For Internal Use ONLY: j
This form can be used for single or multiple wells
1.Well Contractor Information: f
Billy Kennedy 14.WATER ZONES i
FROM TO DESCRIPTION
Well Contractor Name
2834-A
NC Well Contractor Certification Number 15.OUTER CASING for multi-ea wells OR LINER if a lieable
FROM TO DIAME77iR THICKNESS MATERIAL
Kennedy Well Drilling ft. ft- 6;25 in. SDR-21 PVC
Company Name 16.INNER CASING OR TUBING cother at closed-lomil
1/� /� / r FROM TO DIAMETER THICKNESS MATERTAL
2.Well Construction Permit#: d Q0 —6000,Z 4FJ I ft. a ft. in. ��G
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 SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑MunicipaMblic ft. ft. in.
ft. ft. in.❑Geothermal(Heating/Cooling Supply) 29csidential Water SuPPtY(single)
❑Industrial(Commercial ❑Residential Water Supply(shared) 18•GROUT
FROM TO MATERIAL EDIPLACEM ENT METHOD&AMOUNT
❑]rri ation 0 ft. 20+ ft- Bentonite Hydrate chips in place
Non-Wafer Supply Well:.
tt. rt.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO ft. rt. MATERIAL I EMPLACEMENTMETHOD
❑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 soiVrwk type,grain stir,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks ft'
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tx R. Ile ft. — 6,O n dwAl
4.Date Well(s)Completed: Well ID#
ft. fr. G
5a.Well Location:
R. ^ ft.
too rcl 14CO'11 S ft. �J N
OV 9
Facility/GWnei Name Facility 1D#(if')lplicable) ft. ft.
l 1, ft. n1Mk SECTION
Physical Address City,and Zip It.REMARKS F
County Parcel Identification No.(PIN) t 1K /
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certifica on:
(ifwell field,one lat/long insufficient)
N W
Signature o rtified Well Contractor Date
6.Is(are)the well(s): ermanent or ❑Temporary By signing this form.I hereby certify that the uell(s)was(were)constructed in accordance
�� with ISA NCAC 02C.0100 or 1 SA NCAC 02C.0200 If ell Construction Standards and that a
7.is this a repair to an existing well: ILYOS or am copy of this record has been provided to the well owner.
If this is a repair,fill out lmonn well construction information and explain the nature of the
repair tinder#21 remarks section or out 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
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY uith the same construction,you can
submit oneform. SUBMITTAL tNSTUCTIONS
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9.Total well depth below land surface: at (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdderent(example-3C200'and 2@100') construction to the following;
10.Static water level below top of casing: to (ft.) Division of Water Resources,Information Processing Unit,
Illvater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
IL Borehole diameter' 6.25 (in.) 24b.For Infection 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
13a.Yield(gpm) b Method of test: Air 24c.For Water Supply&Infection Wells:
Also submit one copy of this form,within 30 days of completion of
Granular Hypochlorite well construction to the county health department of the county where
13b.Disinfection type: Amount: 10 A_z
constructed.
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Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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