GW1-2021-00754_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:
Bill Kennedy 14.WATER ZONES
Y Y FROM TO DESCRIPTION
Well Contractor Name ft. ft i
2834-A G rr. rL
NC Well Contractor Certification Number 15.OUTER CASING for mul' wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling Q fL I fL 6.25 "" 1 SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING eothermaI closedaoo
M FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: Moo/c!�6 t- ft. fL in
List all applicable well permits(i.e.County,State,Variance,Injection,etc) ft. tt, in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public n- ft- in.
❑Geothermal(Heating/Cooling Supply) GRIGidential Water Supply(single) ft ft. in
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri ation 0 ft. 20+ ft- Bentonite Hydrate ships in place
Non-Water Supply Well:
ft. fL
❑Monitoring ❑Recovery
Injection Well: fL fL
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
FROM TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrie
iw 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,hardnM soiVrock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft �/ It. 2
rc. it. QI A 1
4.Date Well(s)Completed: -.S'o� Well ID# W"
s- It.
fL
5a.Well Location:
LX.Lyy'd 'Al I ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
ramr t. r
.>^s t.aty rew i ft. fL
Physical Address,City,and Zip t_s
21.REMARKS
gla- ��.a�, ?6999a0&a3 _
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: 11 ,I PSI s; r5�rfll�t5 lltli
(if well field,one lat/long is sufficient)
N W - A9.4 � �� -s= -a
�� Signs Certified Well Contractor Date
6.Is(are)the well(S): IJYermanent or ❑Temporary By signing this form,I hereby certify that the wells)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 21Vo copy of this record has been provided to the well owner.
7fthis 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: l 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: aOs_ (tL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3Q200'and 2®1001 Construction to the following.
10.Static water level below top of casing: 2-0 (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 Injection 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
(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
I ,
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
Granular Hypochlorke � well construction to the county health,
13b.Disinfection type: Amount: department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013