GW1-2021-00655_Well Construction - GW1_20210203

WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.
Billy Kennedy FROWATER ZONESM TO DESCRIPTION
Well Contractor Name (p it ft' a ryt
2834-A 't ft
NC Well Contractor Certification Number 15.OUTER CASING for multi-eased wells OR LINER if a ►icable
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling Q ft. ;(l ft. 6.25 in 188-21 Galvanized
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
rJ FROM TO DIAMETER THICKNESS MATERIAL
,
2.Well Construction Permit#: 67(Okit7 U)F—L ft. ft. in.
List all applicable well permits(i.e.Coun y,State,Variance,Injection,etc.)
ft. ft. in.
3.Well Ilse(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL -
ft. R. in.
DAgricultural ❑Mum ' I/public
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) tr. ft. rn.
❑Industrial/Commercial OResidential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Olrri ation 0 ft. 20+ ft. Bentonite Hydrate chips in place
Non-Water Supply Well; ~
- ft ft.
❑Monitoring ORecovery
Injection Well: ft. ft.
OAquiferRecharge ❑Groundwater Remediation 19,SAND/GRAVEL PACK if a licablc
FROM I TO I MATERIAL I EMPLACEMENTMETHOD
❑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 nectssarD
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIP ox color,hardness caillrock n d7e etc.
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under#21 Remarks) ft. t� ft.
1^ ft. 1,57 ftt,�
4.Date Well(s)Completed: — n1 eli IDt# ft. ft. `� 4
7
Sa.Well Location:
� a.I A 4Z C C4W` ft. J ft.
y
Facility/OwnelrName // Facility ID#(if applicable) ft ft.
3�1� / ,6g11e!r'f A- red ft ft.
Physical Address,City,and Zip 21.REMARKS
A tam cc rl C'e- �SfS z21 a 3 2 2.q
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one Iatilong is sufficient) j�
N W zvA �a a a49a 1
Signatu Certified Well ContractoU Date
6,Is(are)the well(s): 2rmanent or ❑'Temporary }ly signing this form,I hereby cerlifj•that the well(s)was(were)constructed in accordance
frith 15A NCAC 01C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well-`- ❑Yes-or QNo - - - copy of ihis record has been provided to the well owner. -- _ _
if this is a repair,fill out knowm well construction information and explain the nature of the
repair under=11 remarks section or on the back oj'this form. yam,y," t; •. ite diagram or additional well details:
r o Yob may use the back of this page to provide additional weil site details or well
a -' a construction details. You may also attach additional pages if necessary.
8.Number of wells constructed: / y p g
For multiple injection or non-water supply wells ONLY with the same consrracpon oy�c�an� q�
submit oneform. i' r- d L�4iUBMITTALINSTUCTIONS
i
9.Total well depth below land surface: 2 •' W A11 N'ells: Submit this form within 30 days of completion of well
'; , _; d
For multiple wells list all depths ifdifferent(example-3@200'aliA7g100Z)','•'•• Co struction t0 the following:
10.Static water level below top of casing: "f Q (ft
) Division of Water Resources,Information Processing Unit,
If wirer level is above casing,use" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: (in.)
6.25 24b.For Injection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: P 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 Alf 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) U Method at test: Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: granular hypocholdte Amount: /?iz well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources ReNised August 2013