GW1-2021-00071_Well Construction - GW1_20211109

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
BillyKennedy 14.WATER ZONES
Y FROM TO DESCRIPTION
Well Contractor Name ft. ft. �d A
2834-A SO a. 5-5'-fL e
NC Well Contractor Certification Number 15.OUTER CASING for multi sed wells OR LINER if a livable
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling 0 ft. ft- 6.25 in. I SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL____
2.Well Construction Permit#:�nc/- DD/a� ftft. in.
List all applicable well permits(.e.County,State,Variance,Injection,etc.)
ft. fl. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑M cipal/Public ft. ft. in.
[]Geothermal(Heating/Cooling Supply) laResi&ntial Water Supply(single) ft' ft. in.
❑lndustriaUCommercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
[]Irrigation 0 ft. 20+ IL Bentonite Hydrate chips in place
Non-Water Supply Well: ft. R.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
fL ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,sofurock in sirx etc.
(explain D It. 'L T t�l
❑Geothermal eatin Coolin Return ❑Other under#21 Remarks
4.Date Well(s)Completed: 119-I/-21 Well ID#
ft. 30 ft. rt G . Sa«c�
Sa.Well Location: It. ft.
Ph'I Sunless con, U ft. o10� R' O ! G
Facility/Owner Nam Facility ID#(if applicable)
M ft.
ft. ft. I IF --
Physical Address,City,and Zip 21.REMARKS
27ZZ'Z6419/
County Parcel Identification No.(PIN) ECT�QN
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: RQC 1 I
22.Certification:
(if well field,one IaUloag is sufficient) ea' ('�FQRItAATIQrI P
Signature ofVrtified Well Contractor Date
6.Is(are)the well(s): a ermanent or ❑Temporary By signing this form,I hereby certify that the tvell(s)was(were)constructed in accordance
�_� with 15A NCAC 02C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 2flii 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 ofthe
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: Cu/S (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ii dijjerent(example-3(200'andd 2,,@100) construction to the following:
10.Static water level below top of casing: 61 (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: 4niaddition 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: 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) /0 Method of test: Air 24c.For Water Supply&Injection Wells:
Also Submit one copy of this form within 30 days of completion of
Granular Hypochlorite well construction to the county health department of the county where
13b.Disinfection type: Amount: �DO�
—� constructed. i
i
Form GW-I North Carolina Department o£Environment and Natural Resources-Division of Water Resources Revised August 2013