GW1-2021-00718_Well Construction - GW1_20211208

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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
FROM TO DESCRIPTION
Well Contractor Name O ft H. 'M
2834-A rt. ft-
OUTER Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a licable
FROM TO DIAMETER THH9 s MATERIAL
Kennedy Well Drilling 0 1 7q ft. 16.25 '- I SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
,A-07 23 FROM TO DIAMETER TmCtdVFSS MATERIAL
. 2.Well Constriction Pert#:_ K ft R. in.
List all applicable well permits ri.e.Couny.State,Variance,Injection,etc.)
ft [[. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT S17F. THICKNESS MATERIAL
ft❑Agricultural ❑Municipal/Public ft in.
❑Geothermal(Heating/Cooling Supply) 0(gidential Water Supply(single) ft ft in
❑hidustrial/Commercial ❑Residential Water Supply(shared) I&GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri ation 0 ft 20+ ft. v
Non-Water Supply Well:
ft. ft
❑Monitoring ❑Recovery
Injection Well: fL ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK Cif applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft.
❑Aquifer Test ❑Stormwater Drainage
th ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DES CRIP ON co h r ha ness,soiVrock typc in size,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft IL
4.Date Well ��s)Completed: /WellID# ft. 30 It. ^
ft' 0 ft G
5a.Well Location: ft. ft.
Pkr l v-ea"ss 4�VA ft ft
Facility/Owner Name Facility ID#(if applicable)
ft
p d/ . ft.
& /p f of a ri ��f_ K o ft ft.
Physical Address,City, nd Zip
21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one tattlong is sufficient) /
N W � �4i�� �I- /7�°��I
- SignaturvifAcrtified Well Contractor Date
r 6.Is(are)the well(s): 2 'manent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or I5A NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or Ia'IVo copy of this record 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 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
8.Number of wells constructed: r 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: 1 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: �� (ft.) Division of Water Resources,Information Processing Unit,
lfwater level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
I I.Borebole diameter: 6.25 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
Rotary 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 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) !J Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this forni within 30 days of completion of
Granular Hypochlorite gD well construction to the county health!department of the county where
13h.Disinfection type: Amount: Z constructed. I
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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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