GW1-2021-04612_Well Construction - GW1_20210510

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—W'itiicwaaiiac'vni.�i'.
This form catrbe used for single or multiple wells
1.Well Contractor Information:
{� 2�Z1 14.WATER ZONES
Billy Kennedy i
V 1 'J FROM TO DESCRIPTION
Well Contractor Name /h
3t�0 rra�^U.
1n�
2 ft. fr.
834-A
Irif:,clr r ��c ,on
NC Well Contractor Certification Number '31 15.OUTER CASING for maltYcased welts OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling ft fL 16.25 f>x SDR-21 I PVC
Company Name 16.INNER CASING OR 7LINGigeothermal closed-loo
n 0004501481141
1 / FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 01a I `6` ®�17 fl. fr. is
bst all applicable,vell permits(i.e.Count)4 State,Variance.Injection,elc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Flt0M TO DIAMETER SI.(Yr SITE THICKNESS MATERIAL
uAgricuiturai DMunicipal/Public
❑Geothermal(Heating/Cooling Supply) 01r9idential Water Supply(single) & % in.
❑industrial/Commercial ❑Residential Water Sutrply(shared) 13.GROUT
❑lrri ation 0 ft. 20+ fL Bentanite Hydrate chips in place
Non-Water Supply Wei ft. ft
❑Monitoring ❑Recovery
ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifs livable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier It. ft.
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DES ON(color.hardness,sautra& ata err.
,OGeothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks
4.Date Well(s)Completed: 7 iO„�Well ID#
ft. O ft.
Sa.Well Location: g• ,
staniry aRo,�,at� ft. ytft.
Facility/Owner 1 ame Facility ID#(if applicable)
1 � ft. ft.
T6 0 i.��,cl t3/t G��f� ft. ft.
Physical Addr s,C'ty,and Zip 21 REMARKS
rl V70 �&8?79
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 AiR
/� Sign ertified Well Contractor � Date
6.Is(are)the well(s): 13Permanent or ❑Temporary By signing this form,I hereby certify that the wells)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 12KO� copy of this record has been provided to the well owner.
lf'this is a repair,fill out known well construction mlbrmation and explain the nature of the
repair under d2l 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 welt
8.Number of wells constructed: / construction details. You may also attach additional pages if necessary.
Tor 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: j'TJ (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 1@100') construction to the following:
10.Static water level below top of casing: 7Q (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+• 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
o 24a above, also submit a copy of!this form within 30 days of completion of well
12.Well construction method: t? construction to the following: I4I
(i.e.auger,rotary;cable,dices 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: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b,Disinfection type: granular hypocholrke Amount: fee'L• well construction to the county health department of the county where
constructed. 1
Form GW-J North Carolina Department ofEnvironment and Natural Resources—Division of Water Resources Revised August 2013