GW1-2021-00736_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells '
1.Well Contractor Information:
Belly Kennedy 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. to 5- fL
2834-A ft. 7 fL
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells ORLINER if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling 0fL .l-fL 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#: ft. ft. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
t4 fL in.
3.Well Use(check well use): 17 SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
EA//gricultural ❑MunicipaUPublic ft. ft. in.
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft ra
❑Industrial/Commercial ❑Residential Water Supply(shared) 1R GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
01rri ation 0 ft- 20+ fL Bentonite Hydrate chips in place
Non-Water Supply Well:
i4 fL
❑Monitoring ❑Recovery
Injection Well: fr. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK 1f a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
ft. fL
❑Aquifer Test ❑Stormwater Drainage
fL ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRD'TION color, ness,soilt ock type,grain size,etc.
❑Geothermal(HeatingtCoolin Return) ❑Other(explain under#21 Remtirits) 6 ft IL ^
Oft. o ft. 6 n [`
4.Date Well(s)Completed: � 3'.2 t1 Well ID# J
r►,r1 ft. �R. /L
5a.Well Location: �1{ I� J�/ ft. ft. l
.&A w W VN G/S ft. ft.
Facility/Owner Name Facility ID#(if applicable)
fie ft.
Physical Address,City,and Zip
21.REMARKS 1
County Parcel Identification No.(PIN) ;,r„
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: I I It ii',, s^t1, S Ut.G,UIN I
(if well field,one lattlong is sufficient)
35;s1srb7 N 7`t-336ar. 7 w tSi�, f l�-/3 tidal
Signature6pCcrtified Well Contractor Date
6.Is(are)the well(s): CJPermanent or ❑Temporary By signing this form,1 hereby cerhjy 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 2<0 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 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 of non-water supply wells ONLY with the some construction,you can
submit oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: �O. (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifjerent(example-3Q200'and 2@100) construction to the following:
10.Static water level below top of casing: e� (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
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) Air 24c.For Water Supply&InjectionIVVells:
S� Method of test:
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: &e> constructed. '
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
I
i