GW1-2021-03522_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 I
1.Well Contractor Information:
14.WATER ZONES
Billy Kennedy FROM TO I DESCRIPTION
Well Contractor Name o ft. 9
2834-A ft
NC Well Contractor Certification Number 15.OUTER CASING for multi coded wens OR LINER ifs ticable)
FROM TO DIAMETER THICKNESS I MATERIAL
Kennedy Well Drilling 0 & I 3q ft. 6.25 '- 1 SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
FROM TO I DIAMETER THICKNESS I MATERIAL
2.Well Construction Permit#:AO&I-00000 72 y fr. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
• ft fr. . l in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SITE THICKNESS MATERIAL
ft. ft. in
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) fa it in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUP
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
01trigation 0 ft 20+ ft Bentonite Hydrate chips in place
Non-Water Supply Well:
fr. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifs licable
❑Aquifer Storage and Recovery ❑Salinity Ham FROM Barrier TO MATERIAL EMPLACEMENT METHOD
ft. ft
❑Aquifer Test ❑Stormwater Drainage
& &
❑Experimental Technology []Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DEs ON color hardn soll/roe4 ryM train dM etc
❑Geothermal (Heating/Cooling Return ❑Other lain under#21 Remarks ft fc
r ft. ?, ft. e
4.Date Well(s)Completed:, ".3 -J Well ID# ft. 5- f
5a.Well Location: ft. ft.
�hJ 6u,, ass Eon It. ft. .
Facility/Owner Name Facility iD#(if applicable) ft. ft. tB,
2111y Aa6,te ft. ft l ,-
A:.o�
"Physical Ad s,City,and Zip
21.REMARKS
County Parcel identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 3 l
22.Certification:
(ifwell field,one lat/long is sufficient)
N w 5=3 a0a/
Signature.191tified Well Contractor Date
6.is(are)the well(s): or ❑Temporary By signing this form,I hereby cerllfy that the we (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 rG1Vo copy ofthis record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature ofihe
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: / 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: aO (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferenl(example-3(200'and 2@100) construction to the following:
10.Static water level below top of casing: 10 (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.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: 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
13s.Yield m ��++� Air 24c.For Water Supply&Injection Wells-
Also) (O Method of test: Also submit one copy of this form within 30 days of completion of
13b.Disinfection type:
granular hypocholrite Amonnt: well construction to the county health department of the county where
lDdr
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water,Resources Revised August 2013
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