GW1-2021-03792_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
1.Well Contractor Information:
9 14.WATER ZONES
Billy Kennedy �✓� y, a FROM To DEscRrnnorr
Well Contractor Name a 2�21 is ft. a'�A, 6 .a
2834-A r ft. ft.
.,r r,C,w'.'^Gitrn� t�Ylli
NC Well Contractor Certification Number moo, t 15.OUTER CASING for multi-cased wells OR LINER if a Gcable
�P1Y^�EI„�siC,llt� c.,Y]Qi3 FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling ��'U - f` ft 6.25 ! '- I SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
�}�y� p FROM TO DIAMETER THICIINESS MATERIAL
2.Well Construction Permit#:�2oa l -�fJ(.f//�O 7 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 S17E THICKNESS MATERIAL
' fL ft is ?
❑Agricultural ❑Mun ipaUPublic
❑Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) ft ft in !.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft• 20+ fit- 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 I TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. &
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if oecessa
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION color,hardness soiuroch type,grain si2t,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. a ft.
�✓ ft. ft.
4.Date Well(s)Completed: '�7 o� Well ID# ft. ft.
5a.Well Location,:: L ft. ,
A.�io.MB_S r1�f�e/ ll�Qyptnel ft. ft.
Facility/Owner Name J Facility ID#(if applicable)
�Q ft. ft.
J
�D ( !&/ s ,e� &W C, /LOI ft. ft.
Physical Address,City,and Zip
Q 21.REMARKS
Rd J.h L 61, 96
2V JG C/
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degree§/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one lat/long is sufficient)
N W - �a
/ Signimi o Certified Well Contractor Date
6.Is(are)the well(s): l K.- anent or ❑Temporary By signing this form,I hereby certify tha/!he 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: Oyes or El o 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. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: iiLl!r (m) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijferent(example-3@200'and 2@1001 construction to the following:
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10.Static water level below top of casing: Ogg (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 (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,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) / Method of test:
Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this forme within 30 days of completion of
Granular Hypochlorite well construction to the county health.department of the county where
13b.Disinfection type: Amount: lzDe
constructed.
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Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources ! Revised August 2013
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