GW1-2021-04236_Well Construction - GW1_20210419

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W—r' L CONSTRVCTION RECORD
For totems!Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES
Billy Kennedy FROM TO DESCRIPTION
Well Contractor Name 6 ' till,
2834_A
NC Well Contractor Certification Number IS.OUTER CASING for mu 'l ed wells OR LINER if a ficable
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling 0 fr. I,ter.W ft- 6.25 '- ,5,04;--a J C,
Company Name J- jO / 16.INNER CASING OR TUBING eotherma]closed-loo
FROM TO I DIAMETER I THICKNESS---A MATERIAL
2.Well Construction Permit#: 1 ft. ft. in
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft. in.
3.Well Ilse(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft in.
❑Agricultural ❑Mu ipal/Public
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. h. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18•GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 11 fl. it. Bentonite Hydrate chips in place
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
injection Well: fr. tr.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifs licable
FROM TO MATERIAL I 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 DESCRIPTION color,hardnw,soillrock rain six etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) I ft' fl- �ir
tt. tr. _
4.Date Well(s)Completed: Well IDIticy Rt
Sa.Well Location: �[ ft.
ft. aC ft.
Facility/Owner Name Facility ID#(ifapplicable) fL ft.
.Sf�9 D �/�► T7'� Q/. ft. ft. Cad 3~' w
Physical Addre/�,C.ity,and.Zip 21.REMARKS
it�L�Gv�,o� 6 713 2 49OD 7 9
County—T Parcel Identification No.(PiN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one Iattlong is sufficicrn)
N W
Signatur&tCerfified Well Contracto Date
6.Is(are)the well(s): Ofrmanent or ❑Temporary By signing This form,I hereby certify 1hal the well(s)uas(were)constructed in accordance
with ISA NCAC 02C.0100 or ISA NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 94 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 of this 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-crater supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS'
9.Total well depth below land surface: a (fl.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths{'different(example-3@200'and 2@100') construction to the following:
/
10.Static water level below top of casing: �O (ft) Division of Water Resources,Information Processing Unit,
Iftrater level is above casing,use"*" 1617 Mail Service Center,Raleigh,NC 27699-1617
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11.Borehole diameter: 6.25 (in.) 24b.For Infection 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: 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) J Method of test: A/I- 24c.For Water Supply&injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: HTH Amount:. 47 g. well construction to the county;health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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