GW1-2021-04453_Well Construction - GW1_20210805

WELL CONSTRUCTION RECORD For Internal use ONLY:
This form can be used for single or multiple wells R
1.Well Contractor Information: I1
Billy Kennedy FROM MATER ZONES DESCRIPTION
Well Contractor Name k6, ft. ft 3 /h
2834-A
NC Well Contractor Certification Number 15.OUTER CASING for mul' ed wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling 0 ft- I oZ ft 16.25 in. I SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
�� .-D�O/�DO FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft ft. in
List all applicable well permits rt.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
fL ft in
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) sidential 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+ ft- Bentonite Hydrate chips in place
Non-Water Supply Well:
ft, k.
❑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 DESCRIPTION color,hardness sait/rock type,crain sim etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks ft. 5- ft. r _ S
r� S_ ft. ft f h
4.Date Well(s)Completed: /' 'a Well ID# k. k. G
5a.Well Location: ft. k.
6riye ft. ft
Facility/Owner Name Facility ID#(if applicable) rl
�,/n� ft. ft.
T�IJ L-ewis tS/YILfln le� rt. ft U It
Physical Address,City,and Zip 21.REMARKS
/ldAd,/,a 9&3 rl3 q I-1S3 DWR e
County I Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:'
(ifwell field,one lat(long is sufficient) ••''
� Signature Certified Well Contracto Date
6.Is(are)the well(s): QPermanent or ❑Temporary By signing this form,I hereby certify than the well(s)was(were)constructed in accordance
with iSA NCAC 02C.0i00 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or QN 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: 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: oC�.S (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'andt�2�/@1001 construction to the following:
10.Static water level below top of casing: dt►✓ (ft) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
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ll.Borehole diameter: 6.25 (in.) 24b.For Infection 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 form within 30 days of completion of
GranularHypochiorite well construction to the county health';department of the county where
13b Disinfection type: Amount: ��e_� 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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