GW1-2021-05831_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: 14.� d✓i�wz
Billy Kennedy O q 20 F
ROM WATER O DESCRIPTION
Well Contractor Name `�_R ff D
2834-A afro Processing e. (o2D ft P
NC Well Contractor Certification Number. lrifarrr' D�ti R Se�t'on OUTER CASING for mnl' w 1 OR LINER if a ticable
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling 0 ft- I 61V ft 16.25 in I SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal cloud-too
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: �I -19Q2 0-3�� ft fr. io.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SSE
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. It. in.
❑Agricultural ❑M��nic�al/Public
❑Geothermal(Heating/Cooling Supply) QResidential Warr Supply(single) ft tc
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 fL 20+ IL Bentonite Hydrate chips in place
Non-Water Supply Well:
it. it.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a icable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft.
❑Aquifer Test ❑Stormwater Drainage ft. R.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION color,6ardnae soiuroetr a eta
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks) tJI fftt
.27-0 ) / R
4.Date Well(s)Completed: We11ID# ft
She
ft.
FA,,,
T -• G(/ r
Sa.Well Location: g, fL l
^` ft. ft.
Facitity/OvIm
Name (, / Facility (if applicable) ft. fL
ft. ft.
Physical Addr1 City,and Zip / 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22 Certification:
(if well field,one Iat/long is sufficient)
N W Ct?ii�r Ja oat
Signature coertified Well Contractor CJ Date
6.Is(are)the well(s): Permanent or ❑Temporary By signing this form,I hereby certo that the wells)was(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0100 Well Construction Standards and.that a
7.Is this a repair to an existing well: ❑Yes or 2110- 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
submit one form. SUBMITTAL INSTUCPIONS
9.Total well depth below land surface: MS— (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: (ft) Division of Water Resouftg:s,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter. 6.26 fD) 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
13a.Yield(gpm) t Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form;within 30 days of completion of
13b.Disinfection type: Amount: /0 0�_
Granular Hypochlortta well construction to the county health!department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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