GW1-2021-02291_Well Construction - GW1_20210510

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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: ey,
��C�- 14.WATER ZONES
Billy Kennedy
FROM TO DESCR"ON
WellCwRractorName IYIH1 ft. ft
fL 3
2834-A 1 1 �J U►�i1 0- fL
messing '''
NC Well Contractor Certification Number 'P+Ci1T,31i�n{ACC^t F155.00UTER CASING for m hrmed DIAMETERent OR f a lic 9L
Kennedy Well Drilling pm�rJR S6 i,on
THICKNESS
© ft' (o ft 6.25 i" SDR-21 PVC
Company Name 16.INNER CASING OR TUBING eoihermal closed-1
FROM TO DIAMETER THICKNESSMATERIAL
2.Well Construction Permit#:_3�/9,3 ft ft. in
List all applicable well permits(i.e.County,State,variance,injection,etc.)
ft. ft. is
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft fL in.
❑Geothermal(Heating/Cooling Supply) .2fte—sidential Water Supply(single) fL ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) I&GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft' 20+ fL Bentonite Hydrate chips in place
Non-Water Supply Well: ft fL
❑Monitoring ORecovery
Injection Well: ft fL
❑Aquifer Recharge ❑Groundwater Remediation .19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. ft To MATERIAL EMPLACEMENT METHOD
[]Aquifer Test ❑Stormwater Drainage
ft. ft
❑Experimental Technology tlSubsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Traces FROM TO DESCRIMON odor,hardnegs,saiuroek type,grato shr,etc.
❑Geothermal(Heating/Cooling Return ❑Other(explain under 421 Remarks) ft. I fL a i
ft. Q rt -kC
�C.
4.Date Well(s)Completed: `.23`� Well Ina
fL fL L
5a.Well Location:
fL ft
Facility/Owner Name Facility ID#(if applicable) ft. &
J 6 L f l�.il��l ft ft.
Physical Address,City,and Zip
2L REMARKS
/ud ze DO/6e 1 SG
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat4ong is sufficient)
N W SignuR;iC>'
� Sigma FCertified Well Contractor Date
6.Is(are)the well(s): permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or EK0 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: OL LIS (IL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells fist all depths ifdijferent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: 30 (fL) 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 Injection 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: ` I�t/ V 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
13b Disinfection type granular hypocholrite Amount: well construction to the county health department of the county where
constructed.
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Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013