GW1-2021-00753_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 fa ft.
2834-A ' p R. 3
NC Well Contractor Certification Number 15.OUTER CASING for mai• a ed wells OR LINER if applicable)
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling 67 rt• A ft 6.25 in. I SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: oZ Oa ( " /'S/'7/7 9r`,3 ft. ft. in.
List all applicable well permits ri.e.County,State,Variance,Inj on,etc.)
in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑M cipal/Public
[]Geothermal(Heating/Cooling Supply) eResidential Water Supply(single) ft. R 1°'
❑IndustriaUCommercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft' 20+ fL Bentonite Hydrate chips in place
ft. ft.
❑Monitoring ❑Recovery
Injection Well: A. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. TO
To MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DE SC ION mlur,hardness sell/mck type,grain sve eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. le ft
ft. ft.
4.Date Well(s)Completed:li-a-�f Well ID#
dreffm
ft. r) ft- A H
Sa.Well Location: // J ft. tL
ShanAOt /4 , A/adY it. ft. is
�
Facility/Owner Namc Facility lD#(if applicable)
�/ Q ` �/yl/ � D ft. ft..
2' it / rl f�f yOra-.(Cf:ON 1tfA ft. ft. �1
Physical Ad City,and Zip 21.REMARKS
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: l�r.ir nr I
22.Certification: ,c'�1.;1OL;,(
(if well field,one tat/long is sufficient) �
iP.F��' :i/1•�lt'1;,�c��t.��CjiIV�P /y�F.��
N W'
Signature ertified Well Contracto Date
6.Is(are)the well(s):00er.anent or ❑Temporary By signing this form,I hereby certify that the well(s)was(mere)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 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#11 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�h the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: �� (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths(different(example-3Q200'and 2Q100) construction to the following:
10.Static water level below top of casing: 30 (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 24aabove, 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) 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 Hypochlorite Amount: well construction to the county health department of the county where
�QA/�
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water'Re sources Revised August 2013
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