GW1-2021-01093_Well Construction - GW1_20210305

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
FROM TO DESCRHIITON
Well Contractor Name V, X.,
rL fL
2834-A ft 61 ft
15.OUTER CASING(for mhKcLed wells; OR LINER 91cable
NC Well Contractor Certification Number V6. FROM TO DIAMETER I MATERIAL
Kennedy Well Drilling 0 ft. &7 ft- 6.25 is SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(peothermal dosed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 20,20-0000-3/_5�7 ft ft. in.
List all applicable well permits(i.e.County,Slate,Variance,Injection,etc.) ft. ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICI(NESS MATERIAL
ft. ft in.
oAgricultural OM i 'pal/Public ft. ft. in.
[]Geothermal(Heating/Cooling Supply) esidential Water Supply(single)
01ndustrial/Commercial OResidential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
0brigation 0 ft' 20+ ft- Bentorifte Hydrate chips in place
Non-Water Supply Well: It.
DMonitoring DRecovery ft
Injection Well: ft. &
OAquifer Recharge OGroundwater Remediation 19.SAND/GRAVEL PACK(il'applicable)
FROM TO MATERIAL 1 EMPLACEMENT METHOD
0Aquifer Storage and Recovery OSalinity Barrier ft. ft
DAquifer Test OStormwater Drainage ft. ft
OExperimental Technology OSubsidence Control 20.DRILLING LOG fattach additional'sheets if recess
OGeothermal(Closed Loop) []Tracer FROM TO DESCRIPTION(calor,hardnem saillrock tym&Mtn s ttc.)
DGeothermal(Heating/Cooling Return) 00ther(explain under#21 ammi Q ft. q AeW' ol,
ft. /,0 SA.P
4.Date Well(s)Completed:ol-0-2 Well lD# OA ztv -//
ft. (P 0
5a.Well Location:
"L I ?A-4-
ft
ft. ft
Facility/Owner (,�A�ss
Facility W#(if applicable) ft. ft
!;_k� Fe*_f, re fJ ft. ft
Physical Add ess,City,and Zip 21.REMARKS
.6h A7 k1 76 'Idt 7 1
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifivell field,one latAong is sufficient)
N W
Signature Certified Well Contracg�r Date
6.Is(are)the weIl(s):_2Kerrmment or OTemporary By signing this form I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or IJA NCACMC.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: OYes or C7No 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
repair under 921 remarks section or on the back of this farm. 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 one form SUBMITTAL INSTUCMONS
9.Total well depth below land surface: nC -(ft) 24a. For All Wells Submit this form within 30 days of completion of well
For multiple wells list all depths tfdifferent(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,
If water level is above casing,use"+" 1617 Mail Service Ce uter,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (i11-) 24b.For Infection 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: Rotary 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
13a.Yield(gpm) K- 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 Hypochlodte Amount: /Q, I z well construction to the county hea�I Ith department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013