GW1-2021-00855_Well Construction - GW1_20210305

WELL CONSTRUCTION RECORD `''
�, For in1,'-"Use ONLY:
This form can be used for single or multiple wells 5
�1.Well Contractor Information: � y
Billy Kennedy l��r� 1 14.WATER ZONES
�'` '` FROM TO DESCRIPTION
Well Contractor Name f ^r 94 fr. ft. 02
2834-A ft
NC Well Contractor Certification Number +v 15.OUTER CASING for muI ed wells OR LINER if applicable)
FROM I TO ETER THICKNESS MATERIAL
Kennedy Well Drilling Q ft. ft. ,.(O. ZS-in -a/ 6a 4.14o•z
Company Name I&INNER CASING OR TUBING(geothermal cl-- too
. E FROM TO DIAMETER THICKNESS MATERIAL —�
2.Well Constriction Permit#: W /i/ ft. ft. in.
List all applicable well permits(1 e.County,Stale,Variance,Injection,etc.)
fL ft in
3.Well Use(check well use): 17.SCREEN
LOAgricultural
pply Well: FROM TO DIAMETER SLOT SITE THICKNESS MATERIAL
ft. ft. in
❑Municipal/Publicmal(Heating/Cooling Supply) Residential Water Supply(single) fL it inal/Commerci ❑Residential Water Supply(shared) 18.GROUTaFROM.. _ TO - -MATERIAL - EMPLACEMENT METHOD&AMOUNT n 0 ft. 20+ fL Bentonite Hydrate chips in place
Non-Water Supply Well:
It. fL
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier fL ft
❑Aquifer Test ❑Stormwater Drainage ft. fL
❑Experimental Technology ❑Subsidence Control
30,DRILLING LOG attach additional sheets if necess
❑Geothermal(Closed Loop) ❑Tracer FROM TO' DES ON color hardness.sol0roek etc
❑Geothermal(Heatin Coolin Return) 00ther(explitin under#21 Remarks ft. f.
4.Date Well(s)Completed: "a�a )Well ID# f
ft' t���
5a.`Well Location: ft Ws"'
f'i •
lr I A( !'Q•r fL ft. G�
Facility/Owner Name-" Facility ID#(if applicable)
ft ft.
a0a� Stal ev 61'o�>r RcP . 3 ft. fL
Physical Address,City,and Zip I21.REMARKS
Ala'13 Qn,r-e- 971 g#
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degmes/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
N W '6-1yJ
Signature fied Well Contractor Date
6.IS(are)the well(s): 211ermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed In accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Srandar&and that a
7.Is this a repair to an existing well: Dyes or Ego copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of 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 �1^ SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: �t%� (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of easing: 30 UP Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use•'+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Iniection 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 Rotary construction to the following:
(Le.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
13s.Yield(gpm) 6 Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
Granular Hypochlorite / L well construction to the county health department of the county where
13b.Disinfection type: Amount: ! O
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013