Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
GW1-2021-00982_Well Construction - GW1_20210419
WELL CONSTRUCTION RECORD For Internal Use ONLY: This form can be used for single or multiple wells 1.Well Contractor Information: 14.WATER ZONES Billy Kennedy FROM TO DESCRIPTION Well Contractor Name ft D ft, l l A i 2834-A a0 file a d- ft. ,mt NC Well Contractor Certification Number 15.OUTER CASING for mu1' ed wells 1)R LINER if a lit able FROM TO DIAMETER THICKNESS MATERIAL Kennedy Well Drilling 0 ft- 1 `;(, fit- 16.25 , 1441 Company Name 16.INNER CASING OR TUBING eothermal closed-loop) / FROM TO DIAMETER THICIdVESS MATERIAL 2.Well Construction Permit 4: 36,6 /1/6�.��� cD-0 ft. ft. in 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: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL ft. ft. in. ❑Agricultural ❑M cipaUPublic ❑Geothermal(Heating/Cooling Supply) C3Residential Water Supply(single) ft ft is ❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT Olrrigation 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 I 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 W4- ft' TO DESCRIPTION color,hardness soillrock n etc. ❑Geothermal eatin Coolin Return ❑Other(explain under#21 Remarks & 4.Date Well(s)Completed: rWell ID# 414 v '. 61,ISa.Well Location: - ft. /l r ' 06 it jiQ eS_S - - ft. ft. Facility/Owner Name Facility 110(if applicable) ft. ft. Physical A.ddlress,C, y irty,and Zip 21.REMARKS Ct County Parcel Identification No.(PIN) 5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: .Processing unit (ifwcll field,one latAong is sufficient) Sedan N W A3 la -02002/ Siinaturc&ikertilled Well Contractor Date 6.Is(are)the well(s): QPermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance with 1 SA NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a 7.Is this a repair to an existing well: ❑Yes or Blgo copy ofthis record has been provided to the well owner. If this is a repair,fell 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: f 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 INSTUCI'IONS 9.Total well depth below land surface: T� (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well For multiple wells list all depths ifdifferent lexample-3©200'and 2@100) construction to the following: 10.Static water level below top of casing: •430 (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 Iniection 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 posh 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) 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: Granular Hypochlorite Amount: (6d? well construction to the county health department of the county where constructed. Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013