GW1-2021-08155_Well Construction - GW1_20211109

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Billy Kennedy 14.WATER ZONES t
FROM TO DESCRIPTION
Well Contractor Name fL ft. ` !
2834-A &rft. 010rt.
NC Well Contractor Certification Number 15.OUTER CASING far?!Lit' sed wells)OR LINER if a licable
FROM TO DMETER THICLINFSS MATERIAL
Kennedy Well Drilling rt. ft. 6.25 in. SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 7LO3 rL rt In.
List all applicable well permits(r.e.County,State,Variance,Injection,etc.)
ft. 2 in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTS12Z THICKNESS MATERIAL.
❑Agricultural ❑M�unicipal/Public ft. ft. in.
❑Geothermal(Heating/Cooling Supply) O'Residential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lni ation 0 ft- 20+ fL 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 applicable)
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 DESCRIPTION color,hwtnes selVrock type,grain sin,etc
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks) rt. ft.
/_ fL ft.
4.Date Well(s)Completed: -.Z. Well ID# CO t
ft. ft. ! G
5a.Well Location: ft, ft•
,Twg,q#,i 4- r nq ul f'&Iq, �t✓t rt rt.
Facility/Owner Name Facility ID#(if applicable)
ft. ft.
31 q 4roa.0 lonik.-, fid ft. ft. 9 1
Physical Address,City,and lip
r 21.REMARKS
17
County Parcel Identification No.(PIN) FROCFSSIN 1
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one Iat/long is sufficient)
N W A oZO.Z I
Sigoa Certified Well Contractor Date
6.Is(are)the well(s): ermanent 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 IF copy of this record has been provided to the well owner.
1f 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 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
S.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY rwth the same construcdon,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface- �d,7 (ft.) 24s. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdderent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: (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 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(gpm) K 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 Hypochlorh Amount:e well construction to the county health department of the county where
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constructed.
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Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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