GW1-2021-03401_Well Construction - GW1_20210607

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 Y FROM TO DESCRIM ON
Well Contractor Name ^Ot){ ,3 ft. ft.
2834-A L C 1 A It. ft
NC Well Contractor Certification Number ryEO����,1C��Vn IS.OUTER CASING for multi-cased wells)OR LINER if a ticahle
k* r FROM TO DIAMETER 7'HICIINF 1 MATERIAL
Kennedy Well Drilling k1'tj^VVr,ng kD11 rt. +r- 16.25 ! i° I SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-lootil n FROM TO DIAMETER THICKNESS MATERIAL
• 2.Well Construction Permit#:Ji3�1r / ft. ft. is
List all applicable well 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 SLOTSI7E THICKNESS MATERIAL
❑Agricultural ❑�Municipal/Public ft. ft. in:
❑Geothermal(Heating/Cooling Supply) 17Residential Water Supply(single) % fr, m
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Olrrijiation 0 fL 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 a livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets it riec
❑Geothermal(Closed Loop) ❑Tracer FROM To DES oN color hardness sail/rack type,grain shx etc.
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks rt. ft
ft. ft. r+
4.Date Well(s)Completed:�QN? Well ID# J
ga ft. df
ft. �2 �C
5a.Well Location: ft. ft t�
�ir./Gfif ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. It.
9/39 616Leso'07 ' ft. &
Physical Address,City,and Zip 21 REMARKS
County Parcel Identification No.(PIN)
51b.Latitude and Longitude In degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one lavlong is sufficient) ,,�i(���
IS X61
� Signature ertified Well Contractor Date
6.Is(are)the well(g): E3>rermanent or ❑Temporary By signing this form,1 hereby certify shot the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 91fo— copy ofthis record has been provided to the well owner.
if this is a repair,Jill out known well construction Information and explain the nature of the
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: I 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 INSTUCTIONS
9.Total well-depth below land surface: (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifjerent(example-3@200'anted 22@100) construction to the following:
10.Static water level below top of casing: rQ (it,) 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 Injection Wells ONLY: Jin 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:� Q V construction to the following
(i.e.auger,rotary,cable,direct push,etc.) f i
Division of Water Resources,Underground IDjection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this fortis within 30 days of completion of
136.Disinfection type: Amount:
granular hypochoblte well construction to the county he filth department of the county where
lQt2� constructed.
I
I
Form OW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
f I
i