GW1-2021-04410_Well Construction - GW1_20210805

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WELL CONSTRUCTION RECORD
For Internal Use ONLY: I
This form can be used for single or multiple wells
1.Well Contractor Information:
Billy Kennedy 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name G 0 ft. G5� ft O
2834-AA ft. olo-T ft. a 1 6191114
NC Well Contractor Certification Number 15.OUTER CASING for multi-case ells OR LINER if a licable
FROM TO DIAMETER i I THICKNESS MATERIAL
Kennedy Well Drilling 0ft. y&/ft. 6.25 SDR-21 PVC
Company Name " 16.INNER CASING OR TUBING(geothermal closed-too
/I�%
2.Well Construction Permit#: FROM ft TO ft DIAMETER in. THICKNESS MATERIAL
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 THIClCiESS MATERIAL
❑Agricultural ❑M_/�unicipaMblic ft ft is
❑Geothermal(Heating/Cooling Supply) RIG-. ritial Water Supply(single) ft. fL in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 ft. 20+ & Bentonite Hydrate chips in place
Non-Water Supply Well:
ft. ft
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation FROM 19.SAND/GRAVEL PACK TO if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft. MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
[]Experimental Technology ❑Subsidence Control ft. ft
20.DRILLING LOG attach additional sheets if necessary)
OGeothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock type,grain der,etc.
m❑Geotheral(Heating/Cooling Return) ❑Other(explain under 421 Remarks) toft. ft.
ft. fL d 10 M
4.Date Well(s)Completed:�- -a1 Well ID#
ft. �ft.
5a.Well Location:: ft. ft. on
Cal A Cl wn ft. ft. r
Facility/Owner Name Facility ID#(if applicable) O
'` ft. ft.
U\ ,
�a?I d/lrr (A r -� ft. ft : U(1\�
Physical Address,City,and Zip 21.REMARKS
tyre fro y 3 foccn� Se 1
County 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
Signature of ertified Well Contractor Date
6.Is(are)the well(s): 6d1'ermanent 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 21V 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
S.Number of wells constructed: I 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: RAJ (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@100) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,information Processing Unit,
if water level is above casing,use"+^ 1617 Mail Service Centel,Raleigh,NC 27699-1617
I1.Borehole diameter: 6.25 (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this!form within 30 days of completion of well
12.Well construction method: Rotary 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
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13a.Yield(gpm) 3 Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
]36.Disinfection type:
Granular Hypochlod Amount: A5dk
te well construction to the county health Idepartment of the county where
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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