GW1--00349_Well Construction - GW1_20240112

1
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Billy Kennedy • 14.WATER ZONES_ I
FROM TO DESCRIPTION
Well Contractor Name / ft. MO ft. .S I i.
2834-A t(Oft. lCamrt. G/�
NC Well Contractor Certification Number '15.OUTERCASINC(for`uiidtl cilsu wells)OR LINER(If.applieable).
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling (7 ft. ,3(® h• 6.25 in• SDR-21 PVC
Company Name 16.INNER CASING OR.TURING.(geothermal dosed400p)`: .
/� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: t/ ��� � ft. ft. is
List all applicable well permits(.e.County,State,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use):
• 17.'SCREEN:' '.'.:
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
gncultural nMunicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ,,residential Water Supply(single) ft. ft. In:
._
0 Industrial/Commercial ❑Residential Water Supply(shared) 18:GROUT ..:..:
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrrigation 0 ft. 20+ k• Bentonite Hydrate chips in place
Non-Water Supply Well:
❑Monitoring ❑Recovery ft. ft /sr kaiS
Injection Well: R• ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVEL PACK(if applicable) .
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery 0 Salinity Barrier
ft. ft.
❑Aquifer Test ❑Stormwater Drainage '
ft. ft.
❑Experhnental Technology 0 Subsidence Control :20.DRILLING LOG(attach additional sheets if necessary) - '
❑Geothermal(Closed Loop) OTracer FROM TO DESCRIPTION(color,hardness.son/rock type.grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft• if n• de` •
-
�•�`•�� /� ft. tt. i
4.Date Well(s)Completed: Jt-N Nell ID# / i� o e
^Q_ ft. n c k. 4/t',7gindr'lPr
5a Well1 Location:
� /� I a 5-ft- r���7 .
Ii r Cintrc/CA N 1 �P✓�l�� ft ft ° C D
Facility/Owner Name Facility ID#(if applicable) r 1147.EE
rt. ft. JAN A �, 2021
147.3 (Sea/ i",terc: 4 a ft. ft.
Physical Addres ,an Zip 21EMARs " ,ill.(: :..iE,^Tl ''Sn,f,.x. ;r ( N
I' o,44. 77a air 6,q W
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: ' 22.Certification:
(if well field,one lat/long is sufficient)
N W -6 Jci /3-43
Signature of fled ell Contractor • Date
6.Is(are)the wells): rmanent or ❑Temporary By signing this form,I hereby certify that the wells)was(were)constructed in accordance
with ISANCAC 02C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: DYes or 111I41c copy of this record has been provided to the well owner.
If this is a repair,fill out!mown well construction information and explain the nature of the
repair under#21 remarks section or on the backof this form. 23.Site diagram or additional well details:
J 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 wells ONLY with the same construction,you can
submit one form. J 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 list all depths if different(example-3@200'and 2@100) construction to the following: 1
10.Static water level below top of casing: ,3.5'''. (ft,) Division of Water Resources,Information Processing Unit,
If rater level is above casing,use"4-" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For In➢ection 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.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
n
13a.Yield(gpm) t EL 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 hypocholrite Amount: 161Z well construction to the county health department of the county where
constructed.
Foam GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013