GW1-2021-03685_Well Construction - GW1_20210903

I
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
BIII Kennedy 14.WATER ZONES
Y Y FROM TO DESCRIPTION.
Well Contractor Name ft. V 10 ft• a•J'1 i M
2834-A ft. is .�V
NC Well Contractor Certification Number 15.OUTER CASING for multi-cas ells OR LINER if a Gcable
FROM TO DIAMETER TIDl7P7FSS MATERIAL
Kennedy Well Drilling fL iL 6.25 ;tw z
Company Name 16.INNER CASING OR TUBING eothermal dosed-loop)
J FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: s-e-0& le2 ft. ft. 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 THICKNESS MATERIAL
ft. ft in.
❑Agricultural ❑Municipal/Public
❑Geothermal(14cating/Cooling Supply) esidential Water Supply(single) ft ft is
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
[Irrigation 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 a licable
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.DRII,LING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM To DES oN color,hardness,sail/rock etc.
❑Geothermal eating/Cooling Retum) ❑Other(explain under 421 Remarks) p ft. OZ ft.
4.Date Well(s)Completed: �:31—oZ Well ID#
a ft. fL ro _
ft. ft.
5a.Well Location: S ft. ft
ilykt/ Aug-es.5 ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft ft s
a
Physical Address,City,and Zit 21..REMARKS
Ala n.," --.t ?ke0,V79Dyq gin, unit
County Parcel Identification No.(PIN) 'ritCjl Iti�"r
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwetl field,one lat/long is sufficient)
N w
Signature&I Certified Veil Contractor Date
6.Is(are)the well(s): O ermanent 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 ON-. copy of this 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
S.Number of wells constructed: r 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 INSTUCTIONS
9.Total well depth below land surface: lur (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list a0 depths ifelifferent(example-3Qa 200'annd 22@1001 construction to the following:
10.Static water level below top of casing: W (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 On.) 24b.For Iniection Wells ONLY: 'In addition to sending the form to the address in
Rotary 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 Mail Service Center,Raleigh,NC 27699-1636
,✓ i
13a.Yield(gpm) �J Method of test: Air 24c For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
Granular Hypochiotite `` well construction to the county health department of the county where
]3b Disinfection type Amount: oQt� constructed.
Form GW-1 North Carolina Department ofEnvironment and Natural Resources—Division of Water Resources Revised August 2013