GW1-2021-05823_Well Construction - GW1_20210709

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: f
14.WATER ZONES
Billy Kennedy FROM TO DESCRWnON
Well Contractor Name I ft 6'^ 3 pn
2834-A fA ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR L1 NER if a Rcsble
FROM TO .DIAMETER THICIQVFSS MATERIAL
Kennedy Well Drilling Q 3 ft- 6.25 i- 1 188-21 Galvanized
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
p/ FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 3%7'Gb ft. ft. is
List all applicable well permits(i.e.County,State,Variance,hilectlon,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Wat apply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
fr. & in.
Agricultural ❑MunicipaVPublic
❑Geothermal g/ g Supply) Supply(single)
tc it in
(Heating/Cooling Coolin Su 1 ❑Residential Water Su 1
❑Industrial/Commercial ❑Residential Water Supply(shared) 18,GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 It' 20+ ft. sentonite 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 licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier fr. ft.
❑Aquifer Test ❑Stormwater Drainage _;
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG Witteh additional sheets if niicrosa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness sowroek tyM grain she,etc
❑Geothermal (Heating/Cooling Return) ❑Other(explain under#21 Remarks fL 3 ft
f t- &
4.Date Well(s)Completed: (0-(-�' Well ID#
ft. ft.
5a.Well) on: fr. ft.
�! G ft. ft
Facility/Owner Name cility ID#(if applicable) 0 n 021
fr. fr. 7
�_� � 'mil F
r .. ft ft.
Physical Address,City,and Zip 21.REMARKS ^ IOrI
,edt7/,e-1 zz(3 1 [)VVR becliall
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one]at/long is sufficient)
N W
�� Signature ertified Well Contractor Date
6.Is(are)the we0(s): G2Permanent or ❑Temporary By signing this form,1 hereby certify that the wells)was(were)constructed in accordance
with 1 SA NCAC 01C.0100 or ISA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ❑KS 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 infection or non-water supply wells ONLY with the same construction,you can
submit one form. -� A� SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: oI(N 5 _qt.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths lfdoerent(example-3@200'and 2@I00) construction to the following:
10.Static water level below top of casing: l3 0 (ft) 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 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 Matz 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 form within 30 days of completion of
granular hypocholrite well construction to the county health'department of the county where
13b.Disinfection type: Amount: constructed. r
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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