GW1-2021-05528_Well Construction - GW1_20211013

i
1 I
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells I
1.Well Contractor Information:
I
14.WATER ZONES
Billy Kennedy FROM TO DESCRIPTION
Well Contractor Name ft. ft. i
2834-A ft. ap ft.
NC Well Contractor Certification Number 15.OUTER CASING for mul' wells OR LINER tf applicable)
FROM TO DIAMETER THI/�IESS MATERIAL
Kennedy Well Drilling ft I q&1 ft. 6.25 SDR-21 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
FROM TO =1 DIAMETER THICKNESS MATERIAL.
2.Well Construction Permit#: 3 G I L(� ft fL in.
List all applicable well permits(I.e.County,State,Variance,Injection,etc.) ft
is
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSI7.E I THICKNESS I MATERIAL.
ft fL is
❑Agricultural ❑Mun� ' blic
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft ft in
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18,GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑]rri acion 0 ft' 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 a licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier It. ft.
❑Aquifer Test ❑Stormwater Drainage
it ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG.attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness soil/ruck type,grain sire,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft
ft. ft
4.Date Well(s)Completed: 9-1 :21 Well ID# ft. I C, ft.
5a.Well Location: ,. ft. ft.
Adt'e k tort a L* ft ft.
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
35-7 ft. ft.
Physical Address ,and Zip 21.REMARKS
. . M 00/'P' ODO!/33
County Parcel Idenufication No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lattlong is sufficient) ( •
SignatureaCcrtlficcCfflell Contractor Date
6.Is(are)the well(s): OferImment 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 QNo copy of this record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
1 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: (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 and 2@100) construction to the following:
10.Static water level below top of casing: �e (ft.) Division of Water Resources,Information Processing Unit,
Jf water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
]].Borehole diameter:
6.25 (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
Rota 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method Rotary 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 Ce i nter,Raleigh,NC 276994636
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
lab Disinfection type:
Granular Hypochlorite Amount: well construction to the county health department of the county where
Q�—
constructed.
} j
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
I