GW1-2021-05845_Well Construction - GW1_20210709

WELL CONSTRUCTION RECORD For Internal use ONLY:
This form can be used for single or multiple wells
I.Well Contractor Information: ED
Billy Kennedy gF CE FROM ER ZONES }
FROM TO --DESCRIPTION
Well Contractor Name "' ft. 2 M"
2834-A JUL 0 2021 ft .2 ft.
NC Well Contractor Certification Number a atlOn Processing Unit 15.OUTER A ING for mul wells OR 1,1NER if a 6cable
InIOrin .FROM TO DIAMETER THICKINESS MATERIAL
Kennedy Well Drilling i DWR Section ft. fr• 6.25 188-21 1 Galvanized
Company Name. 16.INNER CASING OR TUBING(geothermal dosed-loop)
way
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: !� N ft. fth'•
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: mom TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft ft in.
ft ft in.
❑Geothermal(Heating/Cooling Supply) �ential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 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(ifapplicable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. fr.
❑Aquifer Test ❑Stormwater Drainage
ft ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets it'neces
❑Geothermal(Closed Loop) ❑Tracer KFROMTo DFSCRH 770N color,bardn soturock ahe era
❑Geothermal(Heating/CoolingReturn ❑Other(explain under#21 Remarksft. `4.Date Well(s)Completed:&`17 c Well ID#Sa.Well Location:
n`� 4 '
Facility/Owner Name Facility 1D#(if applicable)
a'�l i J"'-A"Id ft ft
ft ft
Physical Address,City,and Zip 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certill tion:
(ifwell field,one lat/long is sufficient)
N W 6 a0a 1
Sign Certified Well Contractor Date
6.Is(are)the well(s): 94.1Lnent. or ❑Temporary By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
/ with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ENO 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 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
SUBMITTAL INSTUCTIONS
submit one form.
9.Total well depth below land surface: Ofl/� (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'and 2@100) construction t0 the following:
10.Static water level below top of easing (ft) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
i1.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: A�fO l 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
A 13s.Yield(gpm) Method of test: 24c.For Water Supply Ar Injection Wells:
J' 1T r`!r
Also submit one copy of this form.within 30 days of completion of
13b.Disinfection type: granular hypochlorde Amount: well construction to the county health department of the county where
constructed.
a
Form GW-1 North Carolina Department ofEnvironment and Natural Resources—Division of water Resources Revised August 2013
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