GW1-2021-05830_Well Construction - GW1_20210709

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information: j
iY 14.WATER ZONES
Billy Kennedy FROM TO DESCPJMON
Well Contractor Name O 9 2021
2834-A JUG v
NC Well Contractor Certification Number 111fQ�mat,tfl'{1,9T Ce,On FROM R TONG form D; Hells PT& Iica MATERIAL
Kennedy Well Drilling p�tiR ft- 6.25 i" SDR-21 PVC
Company Name 16.INNER CASING OR TUBING eothermal desed400
FROM I TO I DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: & % in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc)
ft ft is
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE TIRCKNERS MATERIAL
❑Agricultural ❑MunicipaUPublic ft It. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) It. tt• rn
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
9<gatrort 0 ft' 20+ 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 if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft
❑Aquifer Test ❑Stormwater Drainage
ft ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets If necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCPJMON color,hardem selllrock rype6 irmin size etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft ft
ft ft
4.Date Well(s)Completed: &,-, Nell ID# rt, ft
5a..Well Location: / % ft
It.
Facility/Owner Name Facility iD#(if applicable)
ft. ft
`ram ��r� �1/
VD.7 Cf to L'i /LCA_ ft it
Physical Addifss,City,and Zip 21.REMARKS
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
SignaturoVCcrtified Well Contractor .Date
6.Is(are)the well(s): (�rmanent 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 OKI copy ofthis record has been provided to the well owner.
If this is a repair,jul 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
8.Number of wells constructed: I 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. r SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 16 S (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3(200'and 1Q100) construction to the following:
10.Static water level below top of casing: (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
Rota 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Rotary 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
'1 Alf 24c.For Water Supply&Injection Wells:
13s.Yield(gpm) ' Method of test:
Also submit one copy of this form within 30 days of completion of
Gran.err Hypochtorite well construction to the county health department of the county where
13b.Disinfection type: Amount: n--2! constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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