GW1-2021-03402_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:
Billy Kennedy 9 " H ^ D IC WATER ZONES
Ss FROM TO DESCRIPTION
Well Contractor Name I 7 2�21
2834-A J L N X ,S yft. /00 ft
NC Well Contractor CertiScationNumber rroce,_glnfJ.InrSuln'3�ip91 p Unit I&OUTER CASING formul' wens OR LINER ifa 6eable
FROM TO DIAMETER T11>C FSS TERIAL
Kennedy Well Drilling DoNR Seci1°n 0 ft' I ,s ft. 6.25 SDR-21 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loo
FROM TO DIAMETER I TIOCmUYM MATERIAL
2.Well Construction Permit#: IL
ft is
List all applicable well permits(Le.County,State,Variance,Injection,etc.)
ft. f4 is
3.Well Use(check well use): 17.SCREEN
.watepsupply Weil: FROM TO DIAMETER SLOTSVE THICKNESS MATERIAL .
grtcultural ❑Municipal/Public ft ft. to
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft ft in
❑lndustrial/Commercial ❑Residential Water Supply(shared) 13.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Uri ation 0 f" 20+ sr. Bentonite Hydrate chips in place
Non-Water Supply Well:
ft. &❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifa licable
ft &❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
N. ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardn suillrack ea
❑Geothermal(Heating/CoolingReturn) ❑Other(explain under#21 Remarks) ft• oZ fL '
a ft. f4 n e
4.Date Well(s)Completed: Well ID# o ft.
SA,a/A.JWell Location: J � g R
!IY/I 'e_ AaJaiit�I ft ft G[
Facility/Owner Name Facility ID#(ifapplicable)
/- f4 ft
/� 2 8 e C,41, L-Al ft ft.
Physical Address,C 2L REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one ladlong is
N W
__�� Signature�fied Well Contractor Date
6.Is(are)the well(s): ePermanent 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 Standards and that a
7.Is this a repair to an existing well: ❑Yes or [31Vo 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#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
S.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 INSTUCTIONS
9.Total well depth below land surface: /[O� (fl.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths irdii ferem(example-3(200'and 1@100) construction to the following:
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10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.Borehole diameter: 6.25 (in.) 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: 61'r i/ 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
13a.Yield(gpm) Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13h Disinfection type: granular hypochoirite Amount: h2 02 well construction to the county heath:department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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