GW1-2021-00875_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 FFRMATE TO RZONEs DESCRIPTION
Well Contractor Name DO ft. 2 rt.
2834-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for muld-cased wells OR LINER if a livable
FROM TO DIAMETER 1 THICKNESS MATERIAL
Kennedy Well Drilling ft I Ald, f` 6.25 188-21 Galvanized
16.INNER CASING OR TUBING(geothermal dosed-loop)Company Name l FROM TO DIAMETER THICKNESS MATERIAL2.Well Construction Permit#: �t �r1j)4/J J� ft. ft. In.
list all applicable ivell 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 SLOT SIZE THICKNESSI MATERIAL
ft. ft
❑Agricultural ElMunicipal/Public
❑Geothermal(Heating/Cooling Supply) er esidential Water Supply(single)
ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) FR GROAT
FROM TO MATERIAL EMPLACEMENT METHOD&ANOINT
Oltri ation 0 f• 20+ f` Bentonite Hydrate chips`in_place 4
Non Water Supply Well: ft. ft.
❑Monitoring ❑Recovery
ft. fr.
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a llcable
FROM I T I MATERIAL IEMPLACEMENT METHOD
[]Aquifer Storage and Recovery ❑Salinity Barrier It. ft.
❑Aquifer Test, ❑Stormwater Drainage ft- fr.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach additional sheets if necess
❑Geothermal(Closed Loop) OTracer FROM TO I DESCRIPTION color,hardnesm/olUrotk tvire,aralln siu etc.
❑Geothermal(Heating/Cooling Return) OOther(explain under#21 Remarks ft t ft L f t
e. a. 1
nan
4.Date Well(s)Completed:/_'- a� Well ID# ft, tt.
5a..1 (Well)Location:
r�� j'r fL ft.
Facility/Owne-r I,Name J
J Facility ID#(if applicable) A� ft' ft.
4 'I /r(�630" r/ ft. fr.
Ftrysical Addr ss,City,and Zip 21.REMARKS
NQ wl,2 Il �?
S it 7 2,313�
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) f_
.�4^ L (M �
� Signature f ertified Well Contractor Date
6.Is(are)the well(s): a ermanent or ❑Temporary stgning this form,I hereby certify that the wells)nos(were)constructed in accordance
rr 3 20 i rh ISA NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 2<0 r �� I` copy ojthcs record has been provided to tire well owner.
i hi 1 Ts s a repair, ull out known well construction injorinotion and explain the nature the L)4 Xi
j =23.=Site
repair under ZI remarks section or on the back ojthts form. diagram or additional well details:f�r �?in jl l`s
�r :y.J� JC•�;�il''ou may use the back of this page to provide additional well site details or well
S.Number of wells constructed: F/— construction details. You may also attach additional pages if necessary.
hor multiple injection or non-water supply wells ONLY widr the same construction,you can SUBMITTAL INSTUCTIONS
submit oneform.
9.Total well depth below land surface: 24a. For All Wells: Submit this form within 30 days of completion of well
Tbr multiple wells list all depths iil'dierenr(example-3@200'and 2@100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
ljlwater level is above casing,rise" 1617 Mail Service Center,Raleigh,NC 27699-1617 r
625 24b,For Iniection Wells ONLY: In addition to sending the form to the address i
.
11.Borehole diameter: (in.)
24a above, also submit a copy of this form within 30 days of completion of vw
12.Well construction method: Q f y 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
_ Air 24c.For Water Supply&Iniection Wells:
13a.Yield(gpm) �__ Method of test: Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: granular hypocholrite Amount: well construction to the county health department of the county where
constructed.
Revised August
form G W-I North Carolina Department of Environment and Natural Resources—Division of Water Resources 2013