GW1-2021-04411_Well Construction - GW1_20210805

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells j
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1.Well Contractor information:
Bill Kennedy 14.WATER ZONES
Y Y FROM TO DESCRIPTION
Well Contractor Name /�FL (�� ft. t I
2834-A axa a(�IL eYt
NC Well Contractor Certification Number 15.OUTER CASING for i tulf6aUed wells OR LINER if a Gcabie
FROM TO DIAMETER THIC-- MATERIAL
Kennedy Well Drilling 0 1- v R• 6.25 m' 1 188-21 1 Galvanized
Company Name 16.INNER CASING OR TUBING eothermal closed-loo
Z 7 p� FROM TO DIAMETER THICENESS MATERIAL
7ta.!2.Well Construction Permit#: . 7.3 V ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft. 1 in
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3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft❑Agricultural ❑M cipal/Public ft. in
❑Geothermal(Heating/Cooling Supply) QResidential Water Supply(single) R• ft-
in
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation D IL" ;)0 f-It• Bentonite Hydrate chips in place
Non-Water Supply Well:
fL ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifs licable
FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier f< it.
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG lattsich additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DFSCRH nON color,hardness soNmck types Zratn size,etc:
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks ft a R'
1 tt. fL /,(�
.a�4.Date Well(s)Completed: ^�02-D- Well ID#
er
Sa.Well Location: It. ft.
ft.
Facility/Owner Yam. Fac"lity 1D#(if applica le)
� ft. R.
O�(f ll 7 lGl`1 k- L-CJ f /�V. ft ft.
Physical Address,City,and Zip 21.REMARKS O
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one tat/long is sufficient)
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� Signatw ertified Well Contractor Date
6.Is(are)the well(s): I7Permanent or ❑Temporary by signing this form,I hereby cenify 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 LMvo copy ofthis 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 fl21 remarks section or on the back of this form. 23.Site diagram or additional well details:
j You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: / 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 WSTUCTIONS
9.Total well depth below land surface: oZ (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3 a200'and 2@100) construction to the following:
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10.Static water level below top of casing: A (ft) Division of Water Resources,Information Processing Unit,
ifwater level is above casing,use"+" 1617 Mail Service Center;Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For iniection Wells ONLY: inl 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: xz ew y 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
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13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection Wells:
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Also submit one copy of this form within 30 days of completion of
13b.Disinfection type:
granular hypochlorite Amount: well construction to the county healdIi department of the county where
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constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources l Revised August 2013
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