GW1-2021-04243_Well Construction - GW1_20210419

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information:
14.WATER ZONES
Billy Kennedy FROM TO DESCRIPTION
Well Contractor Name /OQ ft 0� ft ts2 I►1
2834-A 2'8'�Z fr• n
NC Well Contractor Certification Number 15.OUTER CASING for mul edwdls OR LINER if a livable
FROM TO DIAMETERS
MATERIAL
Kennedy Well Drilling ft- 6.25 'n SCR-a f lJL,.
Company Name 16.INNER CASING OR TUBING eothermat closed-loop)
/� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: .Q-0 --000 7-s ft ft 1n
List all applicable well permits(i.e.County,State,Kariance,Injection,etc.) I _+
ft ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft ft in. i
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) % ft in. .
❑Industrial/Commercial ❑Residential Water Supply(shared) 1&GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri ation ft. a & Bentonite Hydrate chips in place
Non-Water Supply Well:
fr. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a livable
FROM TO MATERW. EMPLACEMENT METHOD
ClAquifer Storage and Recovery ❑Salinity Barrier � ft.
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG tattach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardnag,wiUrock tqn Erain ghr,etc
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks 0 tt ft Akl�:
fr. IQ ft /li
4.Date Weu(s)CompletedJzV ai Well ID# ft. L
5a.Well Location: &_ ]E �,ft. ft
X l-k y 4.c.Ot e ft ft
Facility/Owy&Name Facility ID#(if applicable)
,II j /� n , ft. ft
4all Aacl e!o r C ee-P K ft ft
Physical Address,City,and Zip 21.REMARKS
- 104 ?G y9 kz& 5- y3
County Parcel ldentification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one Wong is sufficient)
N W & .��CQ I
Signatur 'Certified Well Contractor Date
6.Is(are)the well(s): 26nnanent or ❑Temporary By signing this form,1 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 t0 an existing well: ❑Yes or C?No 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:
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: 30! (fL) 24a. For All Wells: Submit this;form within 30 days of completion of well
For multiple wells list all depths ifdiiferent(example-3@200'and 2@100) construction to the following:
t 10.Static water level below top of casing: ao (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
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ti�1 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: �t! 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
HTH well construction to the county health department of the county where
13b.Disinfection type: Amount: t7a
constructed.
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Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised Augusr2013
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