GW1-2021-04268_Well Construction - GW1_20210805

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WELL CONSTRUCTION.RECORD For late ma]Use ONLY:
Ibis form can be used far.single ormnitiple wells
1,Well Contractor Information:
Billy Kennedy FROM TO DES CRIvn
1 L WWATER M NE•S .
OR
Well Contractor Name ft. 10 ft.
0 i
2834 A ft. 10 ft.
NC Well Contractor CenificraionNumber is. CASING form - edwells ORLttiER:fa 'linable
IROM To DIAMETER: TIOCKNE55 iNATERLAL
Kennedy Well ©raking ft ft 6.25 SDR-21 PVC
Company Karoo 16.INNER CASING OR Ii1131NG{eotherssaf clese&loo
^ FROM TO DIAMLTER THICKNESS MATERIAL
2.'Well Construction Permit#:o^1J-1— QtJtJCiCJ AZ-3 ii ft.
List all applicable well pemritc(Le Couigit State,1tarianm Injection,etc)
ft. &
3.Mrell Ilse(check well use): 17.SCREEN
Water Supply Well: }ItOM TO DIAMETER .'SLOTsm raicKNEss MATFRIAi.
❑Agricultural ❑Municipal/Publ is
❑Geothermal(Heating/Cooling Supply) residential Water Supply(single) fL fl• in
I71ndustrial/Commercial ❑Residential Water Supply(shared) I&GROUT
FROM i TO I MAT£R1AL:. EM PLACEMENT MFMOD$AMOIRW
01iri ation 0 fL 20+ fL Bentonite hydrate clips in place
[lion-Water Supply WO:
it. ft.
Orton-Itoring ❑Recovery
Injection Well: R ft
❑.Aquifer Recharge Mroundxiater Remediation 19.SANDIGRAN'EL PACK.ifs licable
FROM TO AIATFRIAL, EMPI-.ACEMENr'METAOD
❑Aquifer Storage and Recovray ❑Salinity Barrier ft. ft.
❑Aquifer Tea i35tormwater Drainage
OExperimental Technology ®Subsidence Control
20.DRILLING'LOG fatlatb additional shuts if necessary)
❑Geothermal(ClosedLoop) ❑Tracer FROM To DESCRTLMON ftalai,hardnmsoitfmcl. ere:[
4Gcothermai(Heating/Cooling Return) DOther( lain under 421 Remarks) ft-
fL
ft. Q ft. Army"
4.Date Wells)Completed:,7-aL- Well ID4 O fL V 's-tL J
Sat.Well L w.oretio
A. f� ft. iL
;c.ke / Ut.njess fl. &
Faa/tiytylOGanerN Jp. ® �Facility M-4(ifappiicable) ft. 91
Phvaml C y,and Zip 21.REIUARK.S
�
sing
Comity i'arccl Idrnnfication No.{PIN)
Sb,Latitude and Longitude in degrees/minutes/seconds or deeimal degrees: 22•Certification:
(ifwell field,one lat/lont,is sufficient)
N W
(S): 7P/ atn Dr Tepoar $inamre enifiod'Well Conoactn � Date
6.Is(art)thewell
13�•signing This form,l hereby certii,thal.Ae r vflt4)nms f+rem)'cotutmcied in actardance
frith 15.4 YCAV 02C.Dl00 or 15,4 NCAC 02C.0200 Well Constnivion Standards and than a
7.iS this a repair to an etdstingw0l, ❑Yes or 12< cope aJ this rrL:nri/has hem prmlded to the iveYl
if this is a repair,fiN oui7,-natrn ireD convnwr/on infarmotiun and explain 11m nature of the
repnrr undder=21 remarks sectiwi ar on the back ofthis fomL 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
R.Number of wells constructed: construction details- You may also attach additional pages if necessary.
For mahiple injection or nonarmer supply amlls iILVLY frith the some cmMcdon,you can .
submit(mefarm. SUBMITTAL INSTUCTiONS
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9.Total well depth below land surface• ✓ (fL) 24a.For All Wells: Submit this form within 30 days of completion of well
Formo&#eixilsA;I all&prhsifd*fferentfeaample-3(a2DD'and2CVd�100) construction tothefollowing:
10.Static water level below top afcasing: 90 (ft.) Division of Water Resourt Ps,Information Processing Unit,
lfreater lerel&abtne casing,use"�+n 1617 Mail Service Center,Raleigh,NC 276994 617
1.Borehole diameter- 6,25 (m.) 24b.For Iniection Wells ONLY: To addition to sending the form to the address in
24a shove,also submit a copy of this form within 30 days of completion of well
12,Well construction method: �Ot2fy construction to the following:
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resources,iimderground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,.NC 276994636
jtr C Method of test:'Air 24c,For Water Supply&Injection Weld:
13a.Yield(gpm) Also submit one copy of this form within 30,days of completion of
GrantdarHypochlotite / well construction to the county health department of the county where
13b.Disinfectiontype: Amount: /oar
constructed-
Farm GW-1 hlorth Carolina Department ofEnviroument and Natural Resources—Misian ol`Water:Resoarces Rniwd August 2011
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