GW1-2021-03790_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
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1.Well Contractor Information:
Bill Kennedy -�"'' �✓ 14.WATER ZONES
Y y s,i a F'� FROM TO DESCRIPTION
Well Contractor Name
2834-A r J 2021 to ft. ft.
NC Well COOI[dC[Or Certification Number ��� ro';l1(;Jy�ll I5.OUTER CASING for mul ed wells OR LINER if a licable
r,"C?S FROM TO DIAMETER TiDC1INESS MATERIAL
Kennedy Well Drilling l4 111,3V;"' ntq ft. ft. 16.25 '° SDR-21 I PVC
Company Name
1 °' 16.INNER CA ING OR TUBING(geothermal closed-loop)
�i2� �27 FROM TO HI DIAMETER TCIavFss MATERIAL
2.Well Construction Permit#: aC(e ft. k. in.
List all applicable well permits(i.e.County,State,Parlance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM, TO DIAMETER SLOT SIZE THICIaVESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft in.
❑Geothermal(Heating/Cooling Supply) 21residential Water Supply(single) ft ft in
❑lndustrial/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 if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft TO ft. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DFscRD' ON color,hardness soillrock etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) ft. o ft
4.Date Well(s)Completed: -/7 e ft. a k• I'oW^2 Well ID# ft. ft
5a.Well Location: ft S ft.
)rh;/ Q 4 q ess Cm. ft. ft.
Facility/Owner Name J Facility ID#(if applicable)
ft. ft.
ft. ft.
Physical Address,City,and Zip
21.REMARKS
2A 7 77776/tss'
County W Parcel Identification No.(PiN)
5b.Latitude and Longitude.in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one lat/long is sufficient)
N W - 20
� Signature f ertified Well Contractor Date
6.Is(are)the well(s): nlP ._ anent 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 2<0 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 ofthis 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. ^ r SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: OWJ (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifjerent(example-3@200'aannd 2@100� construction to the following:
10.Static water level below top of casing: 1.21 00 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 (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.)
Division of Water Resources,iUnderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
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Air 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test: Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Amount:
Granular Hypochlorite /0 0> well construction to the county health department of the county where
� constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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