GW1-2021-00833_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:
Bill Kennedy/ 14.WATER ZONEs
Y 7 FROM TO DESCRIPTION
Well Contractor Name / ft. /ls ft M
2834-A Ma 0 ft. G ft. „
NC Well Contractor Certification Number 15.OUTER CING for mul wells)ORNf a cable
FROM DAMETER MATERIAL
Kennedy Well Drilling ft. I OSft 6.25 in SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING eothermal dosed-loop)
/ ��) FROM TO DLAMETER TIQCKIVESS MATERIAL
2.Well Construction Permit#: t�C1/t�o/t-C w ft ft in.
List all applicable well permits(l.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
ft ft in.
❑Agricultural ❑M ipaUPublic
❑Geothermal(Heating/Cooling Supply) C3Residential Water Supply(single) ft' I ft in.
❑Industrial/Comrnercial ❑Residential Water Supply(shared) I&GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 ft 20+ ft Bentonite Hydrate chips in place
Non-Water Supply Well:
ft. ft.
❑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 ft ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRE LLING LOG attach additional sheets if necessary)
❑Geothermai(Closed Loop) ❑Tracer FROM TO DESCRIPTION corn.hardnem saillreck type,grain shm,etc.
❑Geothermal(Heating/Cooling Retum) ❑Other(explain under#21 Remarks) 0 ft. a ft
ft. ft.
4.Date Well(s)Completed: aoa Well ID#
ft O ft K
5a.Well Location: ft ft.
p d�Gr `
Jose a nol Lu c%ha G ft ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
&0 X ll t s Sf ft. ft.
Physical Address,City,and Zip 21.REMARKS
County J / Parcel Identification No.(PN
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
Oa
� r ,J 20 L ignature ertified Well Contractor Date
6.Is(are)the well(s): 2 ermanent or ❑Temporary ` `V
8J'signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A 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 'Lf1Vo. copy ofthis 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 I
repair under#21 remarks section or on the back ofthis form. 23.Site diagram or additional well details:
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 oneform. !! SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: LCl�� (fL) 24a. For Ail Wells: Submit this(form within 30 days of completion of well
For multiple wells list all depths ifali ferent(example-3@200'acid 2/@y 1001 construction to the following:
10.Static water level below top of casing: f U (ft.) 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 On-) 24b.For Infection Wells ONLY: 1n 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: 4oh-A `/ 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 276994636
13s.Yield(gpm) p�1U/ Air 24c.For Water Supply&Injection Wells:
A Method of test:
Also submit one copy of this form within 30 days of completion of
lab Disinfection type Amount:
granular hypocholrtte 9692— 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 Revised August 2013