GW1-2021-05543_Well Construction - GW1_20211013

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WELL CONSTRUCTION RECORD For Internal Use ONLY: j
This form can be used for single or multiple wells
1.Well Contractor Information:
�.. 021 FROM
WATER ZONES
Billy Kennedy
_ � a FROM TO DESCRIPTION
Well Contractor Name IJ ft. ft 4
111 J
2834-A
{.3((�3� 'p J� IS.OUTER CASING for multi wells OR LINER if a livable
NC Well Contractor Certification Number. �(Sr D�7 FROM TO DIAMETER TIDC[�iFSS MATERIAL
Kennedy Well Drilling ft. 33 ft.
t 6.25 `° SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal dweddoo
y.�� ^7 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Constriction Permit#: eCOA�I1- D(.(/l/l/Q-!k ft ft• °
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ff. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft ft in.
❑Agricultural ❑M�unicipal/Public
❑Geothermal(Heating/Cooling Supply) e<.idential Water Supply(single) ft ft in
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL' EMPLACEMENT METHOD&AMOUNT
[Irrigation 0 fl' 20+ ft. Bentonite Hydrate chips in place
Non-Water Supply Well:
ft ft.
❑Monitoring ❑Recovery
Injection Well: ft. FL
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a livable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM To DES ON color,hardness,soil/rock PAie,grain shw,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) ft. ft.
ft ` ftAl
� c�
4.Date Well(s)Completed: 9 a.�a►Well ID# ft. nrJ ft
5a.Well Location: // it. o_, ft �OG�
L[egue iA.- G ` ft. ft.
Facility/6tvner Name Facility ID#(if applicable)
l3
G ,� ft. ft
D ,D r.'r/� ft. ft.
Physical Address Ci ,and Zip 21.REMARKS
County I Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one latflong is sufficient)
N W
SignaturEA Certified Well Contractor Date
6.Is(are)the well(s): 2Termanent 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 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ❑No 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#11 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: nl tJ (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferem(example-3Q200'and 2f@I00) construction to the following:
10.Static water level below top of casing: OI•.0 (ft.) 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 Iniection 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 Center,Raleigh,NC 27699-1636
/13a.Yield(gpro) Method of test:
Air 24c.For Water Supply&Injection Wells:
J
Also submit one copy of this form within 30 days of completion of
Granular Hypochlorite well construction to the county health department of the county where
13b.Disinfection type: Amount:
constructed. i
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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