GW1-2021-03788_Well Construction - GW1_20210903

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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:
p-� s 14.WATER ZONES
Billy Kennedy 6"�ri.:w - FROM TO DESCRIPTION
Well Contractor Name .j 61 2 ft. ft. ya CA! ^I
2834-A S r r. l
r rr�r✓:.wing!Jlil1 ff ,Soft 3
NC Well Contractor Certification Number 3e'r'11 t 15.OUTER CASING for multi-cased ORLINER ifa Gcable
IU OCI7 FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling Q ft- I X ft 16.25 i in I SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
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Oil/}�o/� / FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#:20,2t- I W to - 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 ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) l�idential Water Supply(single) ft. ft, in
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
❑Irri ation 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 ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
rL 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 sot/rock type,gr2in Am,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 10
& 0 ft.
ft ft.
4.Date Well(s)Completed: 611 ID#
Sa.Well Location: q �f ft. ft.
�T kP r WOd Q ft. ft.
Facility/Owner Name Facility lD#(ifapplicable) ft. ft.
T6 0 u ,e/'/ Y y,*.f le 2 ft. ft
Physical Adds,City,and Zip 21.REMARKS
,<a�o(d�d� k7030 7-7-531
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwe0 field,one lat/long is sufficient)
N W G(/ �.0 n tit 1 v'Orw
Signature&6rtifiefl VTeTContractor Date
6.Is(are)the well(s): � rmanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 1:33Q0 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
8.Number of wells constructed: J 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: ;L4r (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and 2@1001 construction to the following: -
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10.Static water level below top of casing: v�0 (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Tenter,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Initrtion Wells ONLY:i 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: ry 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) Method oftest: 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: ,� well construction to the county health department of the county where
�_
constructed.
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Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013