GW1-2021-00749_Well Construction - GW1_20211208

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This tbtm can be used for single or multiple wells
1.Well Contractor Information:
Billy Kennedy 14.WATER ZONES
FROM TO DESCRIPTION
Well Commctor Name 0 ft. ft.
yq I 17•l
2834-A 3 ft- 390 ft
NC Well Contractor Certification Number 15.OUTER CASING for multi cased OR LINER if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drifting p rL ft- 6.25 in. SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed400 )
`/ FROM TO DIAMETER THICKNESS MATERTAL
2.Well Construction Permit#: .3 72 G D ft. fr. 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 SLOTSIZE THICKNESS MATERIAL
ft. in.
OAgricultural ❑Municipal/Pub)ic
❑Geothermal(Heating/Cooling Supply) 2liesidential Water Supply(single) ft- It-
in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 ft. i 20+ It- Bentonite Hydrate chips in place
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
injection Well: ft. rt-
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifapplicable)
FROM TO MATERIAL EMPLACEMENT'NIXTHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG(attach additional sheets it necessary
❑Geothermal(Closed Loop) (Tracer FROM I TO DESCRIPTION(color,hardness soillrock type,gmin sbc,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) R• ft. Q
ft. tt.
4.Date Well(s)Completed: r Well ID# 42� ft. R.
5a.Well Location: /� I ft. R.
6 P.S4 6&M GLtS�t r n t ft. tL ��'�`3 �[� f177 F,
Fact ity/Owncr Tilune Facility ID#(if applicable) ft ft r f
/Q[Q G'���R G A ✓Zoarl ft. ft. DEL Ub 2021
Physical Address,City,and Zip 21.REMARKS
Countv Parcel Identification No.(PIN) r p1
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwcll field,one latdlong is sufficient) dd
N W LJ 11-n.r o o �oZ
_ Signatu o Certified Well Contractor Date
6.Is(are)the well(s): (aPermanent or ❑Temporary By signing this(orm.I hereby cerq&that,the uell(s)tras(rrorre)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 l3N. copy of this record has been provided to the it-ell owner.
IJ'this is a repair,fill out knit well construction information and explain the nature oJ'the
repair under 421 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: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply the/Is ONLY frith the same construction,you can
submit oneform. SUBMITTAL INSTUCTIONS
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 fist all depths if different(example-3@200'and 2@000) construction to the following:
10.Static water level below top of casing. t�U (ft.) Division of Water Resources,Information Processing Unit,
" 1617 Mail Service Center,Raleigh,NC 27699-1617
If water lerel is abuse casing,use"+
I].Borehole diameter: 6.25 (in.) 24b.For lniection 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 ry construction to the following:
(i.e.auger,rotary,cable,direct push.etc.) i
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) 24c.For Water Supply&Injection Wells:
tX Method of test: Air
Also submit one copy of this form within 30 days of completion of
13b.Dislnfection type:
Granular Hypochlorite Amount: z
well construction to the county kiealth department of the county where
) fz
constnlctcd.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water,Resources Revised August 2013