GW1-2021-05494_Well Construction - GW1_20211013

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WFUT I(0N-,SUW,CU For internal Use ONLY:
i lus romi can be used}or ingle or multiple wells
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1.Well Contractor Information: @��'
Billy Kennedy R CC 1p 14.WATER ZONES i
_FROM ._TO-----.._ DFSCRiPTION.------
Well Contractor Name OCT
T 1 fr• It.
l.' 202�
2834-A as�Ott. at'S'tr.
NC Well Contractor Certification Numbed.fOrn 3tion Processin FROMUTER CTOSING form DIAME71tRells OR�11 R�tSf a heMA'TERIAL
�WR Section Unit ft. fc 1n
Kennedy Well Drilling 6.25 SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
QL' FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: i 7 7- ft. ft. in.
List all applicable well permits(i.e.County,Stale,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
,�� �C,�nnly tyre(• FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
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❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) Olf�.,,dential Water Supply(single) It. fr. in:
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL I EMPLACEMENT METHOD&AMOUNT
❑irri ation 0 fit' 20+ ft- Bentonite Hydrate chips in place
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well:
ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aq FROM TO uifer Storage and Recovery ❑Salinity Barrier fr. fr. MATERIAL I EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage
fa fr.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardneu soll/mck Pipe,arain sire,etc.
GGeothermar(Heating/Cooling Return) ❑Other(explain under#21 Remarks) e ft- Q
4.Date Welks)Completed: .�WelrHW i tr VGC ft C�6rL
5a.Well Location: .,�� ft. ft.
6egAlr 194 .-S�9a 1- ft. ft.
Facility/Owner Name Facility ID#(if applicable)
Q e D ft. ft.
1�0 /n e /�! ft. ft.
Physical Address,City,and Zip
21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one Willing is sufficient)
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� Signature Certified Well Contracto Date
6.Is(are)the well(s): zlrP ;manent or ❑Temporary By signing this Jorm,I hereby cert66,that fire wetlft),ras(n•ere)constructed in accordance
frith 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 ❑No copy of ihis record has been provided to the well owner.
IJ'this is a repair,Jill out known well construction information and explain the nature of the
repair wider=21 remarks section or on the back afthis 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: f construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply ivells ONLY frith the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: JOS (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
Fur multiple hells list all depths ifdiJferent(example-3 a 200'and 2@100') construction to the following:
10.Static water level below top of casing: 20 (ft.) Division of Water Resources,information Processing Unit,
IJ'ivater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
L Borehole diameter: 6.25 (in.) 24b.For fniection 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) 13 Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
J 13b.Disinfection type: Amount:
Granular Hypochlorite -O'k well construction to the county health department of the county where
constructed. I
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Form GW-I North Carolina Depamnent of Environment and Natural Resources-Division of Water Resources Rc%ised August 2013