GW1-2021-04608_Well Construction - GW1_20210510

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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:
BIII Kenned /� 1 14.WATER ZONES
Y Y i AY •1 2OZ 1 FROM TO DESCRIPTION
Well Contractor Name ft. %
2834_A 4t ,messing ft. ft.
Iris^vrr,OhrL�n �Fv.
NC Well Contractor Certification Number d��VJJ 1,On 15.OUTER CASING for multi cased welts OR LINER if a licable
FROM I TO I THICKNESS MATERIAL
Kennedy Well Drilling 0 ft. I $'ft 16.25 '- 1 SDR-21 IPvc
Company Name 16.INNER CASING OR TUBING othermal dosed-loop)
/� FROM TO DIAMETER THICIOHESS MATERIAL
2.Well Construction Permit#: W1 W [Jf/(J a ro�i'S It. N. in
List all applicable well permits(i-e_County,State,variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM To DIAMETER star sinTFUC104M MATERIAL
❑Agricultural ❑�MunicipaVPublic ft ft is
❑Geothermal(Heating/Cooling Supply) t39esidential Water Supply(single) ft. ft
❑IndustriaVCommercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
01rri ation 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
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. To ft MATERIAL. I EMPLACEMENT METHOD
❑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,hardnem sailfrock type,Cmin sbz,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under 421 Remarks) Q ft- 3 ft ,(d SO f
JO� 3 ft tc ft. /�tr� /n c9 eL
4.Date Well(s)Completed:` (Well ID# �.7�
ft. O ft. did-,I4
5a.Well Location: ft Ife ft !0
-KWJ' 7
k 1 t 5 fi&fdMCc n ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft ft.
68'Ll /\I"4 A4TA1 t , fL 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:
(ifwell field,one lat/long is sufficient)
N w 16 �4 �(�30`JO-2/
/' Signature ertified Well Contractor Date
6.Is(are)the well(s): ]ilPermanent 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 vivo copy of this retard 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-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCfIONS
9.Total well depth below land surface: 19D 00 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: !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
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: _/ V construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) /I
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center;Raleigh,NC 27699-1636
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13a.Yield(gpm) b Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
granular hypocholdte well construction to the county health department of the county where
13h Disinfection types Amount: lee'?
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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