GW1-2021-03515_Well Construction - GW1_20210607

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells j
1.Well Contractor Information:
Bill Kenned 14.WATER ZONES
Y Jy/ FROM TO DESCRIPTION
Well Contractor Name &ft. ft. 30 M
2834-A "10 ft. 9a ft. �
NC Well Contractor Certification Number 15.OUTER CASING for 1 niti-cas ells THICIINESS OR LINER if a hcable
FROM TO DIAMETER MATERIAL
Kennedy Well Drilling 19 fc 11q fL 6.25 ire I SDR-21 PVC
Company Name 16.INNER CASING OR TUBING eothermml dosed-loop)
9 FROM TO DIAMETER TMCKNESS MATERIAL
2.Well Constriction Permit#: V ft ft in
List all applicable well permits(i.e.County,Si Ate,Variance,Injection,etc.)
ft. fL in.
3.Well Use(check well use): IT SCREEN
Water Supply Well: FROM TO DIAMETER. .SLOT SITE THICKNESS MATERIAL
❑Agricultural ❑_MunicipaUPublic ft. fL in.
❑Geothermal(Heating/Cooling Supply) 2Kes//tdential Water Supply(single) ft ft in
❑Industrial/Commercial ❑Residential Water Supply(shared) 13.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑llri ation 0 ft 20+ fL 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 lif applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft TO & MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage fl. M
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM To DES ON color harincts,soilfrock type,yraw shr,etc
❑Geothermal (Heating/Cooling Return ❑Other(explain under 421 Remarks ft. ft.
4.Date Well(s)Completed:i<-' I Well EM S-ft- 3O ft &
rr ft. I�4�
5a.Well Location: � ft. ,e-%
"Ie r S.SO� 1 �r ytt�J.�IT/� ft ft. t�
Facility/Owner Name f / Facility ID#(if applicable) ft ft.
ft. ft.
Physical Address,City,and Zip 21.REMARTLS
t .t
County Parcel Identification No.(PIN)
mYR ecilon
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
N W c° C� O ^o(yo2
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Signature ertified Well Contractor Date
6.Is(are)the well(s): 06".-anent 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.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or a<. copy of this 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 of this 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 one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: �C/� (11.) 24a. For.All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths rfdifferent(example.3 t@200'and 2(Qa 100) construction to the following:
10.Static water level below top of casing: A) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Iniection.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: � �� construction to the following: I
(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) SO Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
136.Disinfection type:
granular hypocholrtte Amount: well construction to the county health department of the county where
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constructed. y
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Farm GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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