GW1-2021-03688_Well Construction - GW1_20210903

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 I DESCRIPTION
Well Contractor Name ft. O ft.
2834-A ft. rt.
NC Well Contractor Certification Number I5.OUTER CASING for mn►ti cased we1Ls OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling 4Q ft. a ft. 6.25 SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
���� FROM TO DIAMETER THICIPIFSS MATERIAL.
2.Well Construction Permit#: 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
M ft in.
❑Agricultural ❑Munici ublic
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) FR GROUT
ROM TO MATrRIAI. EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 ft- 20+ ft- Bentonite Hydrate chips in place
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft &
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO I 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 FROM TO DESCRIPTION color,hardness soiurock type,ffafn sizr,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. fL
p ft. ft.
4.Date Well(s)Completed: "'1 -,Well um
It. 7ils rt O GK
aW /O
5a.Well Loca•on: ft. ft.
ft. ft.
Facility/04ner Name Facility ID#(if applicable) ft. ft.
HTet�) /COS ft. ft.
Physical Address,City,and Zip 21.REMARKS
---
County Parcel Identification No.(PIN) p,i t"t 1'� '•l•
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N W 1�� / O�13--QQ�(
� Signan o Certified Well Contractor Date
6.Is(are)the well(s): ePermanent 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 [;P II' 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 921 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-watersupply wells ONLYwith the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: wS (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 1@1001 construction to the following:
10.Static water level below top of casing:. as (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,nter,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
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.) I ; '
Division of Water Resources,�Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
132.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
Granular Hypochiorite well construction to the county health department of the county where
13b.Disinfection type: Amount:
constructed.
i
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources - Revised August 2013