GW1-2021-00761_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 I�
1.Well Contractor Information:
Billy Kennedy 14.WATER ZONES
FROM TO DESCRIPTION
Welt Contractor Name
ft. c/ft. a �
2834-A pell i
it v � 0
NC Well Contractor Certification Number 15.OUTER CASING for mul' wells OR LINER if applicable)
FROi1f TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling fL ?Ira. 6.25' _i S "Ess Pvc
Company Name 16.INNER CASING OR TUBING cothermaI dosed-loop)
^^,,���^1 / ,J /�� p q FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: aWd( - 0000� I 17 ft. ft iry
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) ft. ft. in.
3.Weil Use(check well use): 17.SCREEN
Water Supply Well; FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
h, ..❑Agricultural ❑M�unicipaUPubhc ft. in.
❑Geothermal(Heating/Cooling Supply) 12<,.dential Water Supply(single) fr. ft. in,
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 20+ ft- Sentanite Hydrate chips in place
Non-Water Supply Well-
f[. ft.
❑Monitoring ❑Recovery
Injection Well: R. ft.
❑Aquifer Recharge ❑GroundwmterRemediation 19.SAND/GRAVELPACK(itapplicable
FROM TO MATERIAL EMPLACEMENTMETHOD.
❑Aquifer Storage and Recovery ❑Salinity Barrier it ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary
❑Gwiherriial(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soiltrnek type,grzin silk,et,
❑Geothermal(Hcating/Cooling Return) ❑Other(explain under#21 Remarks) ft. al tt. A ce
4.Date Well(s)Completed: '�R6ell ID# c.4�..
It. ANft. -
5a.Well Location: ft, t.
ft.
Facility/Owner Name Facility ID#(if applicable)
it. ft. -
3S 3 5 ro e h,-_&r A-e_m 410 u; 8W ft. ft. - .
Physical A��and Zip 21.REMARKS
77,2(2 96o q&
County / Parcel identification No.(PIN) t ;
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: ttf.i•:i lY}'1;,l:ll;l s;i n.F �J17 UI'•_l
(if well field,one ladlong is sufficient)
-Signature cUertified Well Contractor Date
6.Is(are)the ivell(s): 24 ermanent or ❑Temporary By signing this farm,I hereby certify that the❑vell(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Consrntction Standards and that a
7.Is this a repair to an existing well: ❑Yes or PK copy of this record has been provided to the well owner.
If this is a repair,fill our known well construction information and explain the nature of the
repair under#21 remarks section or an 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: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply welts ONLY with the same construction,you can
submit one form. 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 welLe list all depths if different(example-3C-100'and 2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
if water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I L Borehole diameter' 6.25 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
Rotary24a above, also submit a copy!of,this form within 30 days of completion of well
12.Well construction method construction to the folloning:
(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) 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: well construction to the county health department of the county where
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� constructed. �'
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Forne OW-) North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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