GW1-2021-00698_Well Construction - GW1_20211208

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells f
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1.Well Contractor Information:
Billy Kennedy FR WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. 'u
2834-A
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a livable)
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Weff Driffing a f` 6,25 i° SDR-21 PVC
16.DINER CASING OR I." RING(geothermal closed-loop)
Company Name FROM TO DIAMETER THICKNESS �inTF.R1AT.
2.Well Construction Permit#:
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 SI-0 SIZ£ THTCKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Municipal(Pubtic
in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft
18.
❑lndusttial/Commercial ❑Residential Water Supply(shared) FR GROUT
} OM I TO MATERIAL EMPLACEMENT METHOD&,U110UNT
01nigation p it 20+ f` Bentonite Hydrate chips in place
Non-Wailer Sup(tly Well:
❑Monitoring ❑Recovery
Injection Well: R. ft.
❑Aquitcr Recharge ❑Groundwater Remediation 19.SAND/GRAIrEL PACK ita licab►e
FROM TO NA'1'ERIAL EMPLACEMENT. ETHOD
❑Aquifer Storage and Recovery OSalinity Barrier
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control z0,DRILLING LOG attach additional sheets if necessary
❑Geothermal(Closed Loop) ❑Tracer Faonf To DESCRIPTION(color,hardness,soil ro[k r. a Im sire,ern.
❑Geothermal Hcating/Coolin Return) ❑Other(explain under#21 Remarks) o
It. ft. 6
ft. ft.
4,Date Wells)Completed: Well it, ft.
Ile
5a.Well Location:
h[e y 4i 5 of Q PIC2
Facility/Owner N me J/ L' t1 g�Facility ID#(if applicable) ft. ft. G r r
UG S- /y G !'Fu/ y Z/� ft. ft. C
Physical Address,City,and Zip 21.REMARKS
C�a��.✓I .3f kS� iJGTQNI
County Parcel Identification No.(PIN)
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5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwel(field;one ladlong is sufficient) 99
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Signatur Certified Well Contracto Date
6.Is(are)the wetl(s): ermanent or ❑Temporary By signing this form,1 hereby certify that the uell(sj was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 06.000 Well Construction Standards and that it
7.Is this a repair to an existing well: OYes or r o 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 ofthis 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: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water suppty wells ONLY with the same construction,you can SUBMITTAL INSTUCTIONS
submit one form.
9.Total well depth below land surface: 3 0J (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Fin muhiple wells list all depths ifdii ferent(example-3L200'and 2@100') construction to the following:
10.Static water level below top of casing: 30 (ft.) Division of Water Resources,Information Processing Unit,
/f water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
1].Borehole diameter: (in.)6.25 24b.For Iniection Wells ONLY: 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,,Undergrouod Injection Control Program,
FOR WATER SUPPLY WELLS ONLY 1636 Mail Service Center,Raleigh,NC 27699-1636
�1 Air 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) O'L Method of test: Also submit one copy of this fotin within 30 days of completion of
Granular Hypochlorite well construction to the county health department of the county where
13b,Disinfectiontype: Amount: constructed. I'
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Form GW1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised Aueust 2013