GW1-2021-03390_Well Construction - GW1_20210607

WELL CONSTRUCTION RECORD For Imcmal use ONLY:
7 &form can be used far single or multiple wells
1.Well Contractor Information: e,
KennedyKennedy `l4.VYA7'�R7.AN£.S
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l FROM TO DFSCRIPMON
Well CommctorNam 7 20�1 ft as
2834-l4 SUN X o ft. / ,' .
NC Wen ConumorCmuliicationNuodxr In�Crry,3tipn prO,eSSing Vnit IS.0=RCASING frn-rmAri tdx�s OR LINER if FI mbte
tin , ,Ton + �► DraxerLR THK'RSiFSS MATERIAL
Kennedy Well Drilling D f[ p fL 6.25 1- 1 188-23 1 Galvanized
Cody Name 16.114NER CASING-OR TUBb+1G IrcetbermW damd400
^��/iff .�� FROM fr To DIAMETER m Irmc2aiFSS MATERIAL
2.Wen Construction Permit# J: L
List all appirrahlee well permits ftt a Couruy,Sure,Variance,lrtjectimt etc-)
fr. fr. in
3.Well Use(ciaeck well uw)r 17.SCREEN
Water Supply Wen: FROM TO DIANUTER SLOT512Z TRICENM MATERIAL
& ft.
OAgricultural QMunicipal/Public
❑Geothermal(Heating/CoolingSupply) 0tesidential Water Supply(single) ft' tt
❑lndust&WCommereial ❑Residential Water Supply(shamed) I&GROUT
FROM TO MATERIAL UWLACEMEIV-f 141E1110D&AMOUh-r
❑lni 'on fc #0 fL Bentonite Hydrate chips in place
Non-Water Supply Well:
❑Monitoringn ❑Recovery
Injection Well: ft. fr.
❑Aquifer Recharge ❑Groundwater Rernediation 19.SAND/GRAVEL PACK ifia
QAquifer Storage and Recovery QSalinity Barrier FROM B TO. ft. MATERIAL [e-mail]_&WW METHOD
DAquifer Test OStormivater Drainage
fL fr.
❑Experimental Technology ❑Subsidence Control
21K DRILLING LOG attaeb additimA sheets if neeam
❑Geothemral(Closed Loop) ❑Tracer FROM TO D art cola;bardaem acivrark sae etc.
❑Geothermal eating/Coolin Return) ❑Other(explain under#121 Remarks) 0
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4.Date Well(s)Completed: �well HW ��f fi. C n
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5a.Well Location:
A'
v ct Len. ft. &
FacilityiOwnerName Facility 1D9(if applicable)
16D ft. FL
Physical Address'City,and Zip 21.REMARKS
County Pared IdCd6g6ti1Dn No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 Certification:
(if well field,we lat/long is sufficient)
N W l S= I�a0d1
Sigriarur&fCcrtificd well ContractmCl Date
6.Is(are)the well(s): 13r"I.--anent or ❑Temporary By signing This form,I hereby certify that the wells)was(were)constructed in accordance
ivuh 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Melt Construction Standards and that a
7.Is this a repair to an existing wrli: Dyes or 13iYo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction injorntation and explain the nature o17he
repair tauter,21 remarks section or on the hack ofthis farn. 23.Site diagram or additional well details:
j You may use the back of this page to provide additional Nvell site details or well
&Number ofwells constructed: / construction details. You may also attach additional pages ifnecessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form / SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: fL) 24a For All Wells: Submit this form within 30 days of completion of well
For multiple wens list all depths ifdifferent(example-3a200'and2aGI11W) construction to the following:
10.Static water level below top of rasing: r_a v ow Division of Water Resources,Information Processing Unit,
If traterkrel is above casing nee"=" 1617 Mail Service Center,Raleigh,NC 276994617
I1.Borehole diameter: 6.25 (in.) 24b. For Infection Wells ONLY:I In addition to sending tare form to the address in
/Q}
24a above, also submit a copy of this fort within 30 days of completion of well
12-Well construction method: Ae 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
i
13a.Yield(gpm) t7SJl/ Method of test: A t tr 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13h.Ditsiafeetion type HTH Amount: well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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