GW1-2021-01819_Well Construction - GW1_20210419

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WELL CONSTRUCTION RECORD
For Internal Use ONLY:
This form can be used for single or multiple wells I
1.Well Contractor Information: `
14.;WATEA ZONES
Billy Kennedy FROM TO I DESCRIPTION
Well Contractor Name DV ft ez ft. i
2834-A 2 SF` 9-
NC Well Contractor Certification Number 15.OUTER CASING for multi eased w R LINEA if a Gcable
FROM TO DIAMETER THICIOVFSS MATERIAL
Kennedy Well Drilling ft & ft. s.2s _ PA_"
Company Name 16.INNER CASING OR TUBING fteothirmal dosed-loop)
Xt // �• ' FROM TO DIAMETER THICI04M MATERIAL
2.Well Construction Permit#: �� / /YAVi 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_ u�/nicipal/Public
ft ft. in
❑Geothermal(Ileating/Cooling Supply) L-7Residential Water Supply(single)
❑IndustriaUCommercial ❑Residential Water Supply(shared) 1&GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lni ation Q fl. ' ft Bentonite Hydrate chips in place
Non-Water Supply Well:
ft ff.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
[]Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a livable
FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier fa ft
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG tattach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer WOMTO DESCRIMON color hardness soil/rock etc
❑Geothermal eatin Coolin Return ❑Other(explain under#21 Remarks ft 40m_ft
81
4.Date Well(s)Completed:3 ken Elm5a.Well Location: tt _
11,Sl-ih bI 1 Qkfe ft ft off, •` 'v•�
Facility/Owner Named� Facility ID#(if applicable) ft fL �e
ft fL
Physical Address,City,.441P
/� Q �t fig/ 21.REMARKS
County Parcel Identification No.(PIN) ,�ti 'i zlz
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: ,
(ifwell field,one lat/long is sufficient)
N W A, itp 3-a9�aoa l
� Signah Certified Well Contractor Date
6.Is(are)the wetl(s): 01'ermanent or ❑Temporary By signing this form,I hereby cer16 that the well(s)was(were)constructed in accordance
�� with 15A NCAC 02C.0I00 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or !e?1V o copy of this record has been provided to the well owner.
Ifthis 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
S.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY wish the same construction,you can
submit one form. ^ SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: t7w (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 a200'and 2@100) construction to the following:
10.Static water level below top of using: 30 00 Division of Water Resources,Information Processing Unit,
/fwater 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
e� 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 101 i construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injectlon Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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13a.Yield(gpm) Method of test: r r 24c.For Water Supply&Injection Wells:
Also submit one copy of this form;within 30 days of completion of
13b.Disinfection type: HTH Amount: 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 Auguel 2013