GW1-2021-00755_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
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1.Well Contractor Information:
Belly Kennedy 14.WATER ZONES
FROM TO .DESCRIPTION
Well Contractor Name IL ft-
2834-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling 0 ft I fL 16.25 SDR-21 PVC
Company Name 16.INNER CASING OR TUBING eothermaI closed400
��11 ^ ��rr11 q FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 9.0-11— 00000 //6 ft. R. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc)
ft ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑ u�nicipal/Public ft ft. in.
❑Geothermal(Heating/Cooling Supply) 06 idential Water Supply(single) R ft In
❑lndustrial/Commereial ❑Residential Water Supply(shared) 1&GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft' 20+ ft- Bentonite Hydrate chips in place
Non-Water Supply Well:
ft. ft
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifs licable
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. TO
❑Aquifer Test ❑Stotmwater Drainage
f4 ft.
OExperimental Technology ❑Subsidence Control
20.DRILLING LOG attach additionalshects if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION mler,hardness,soivrock type,gnin sae,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) n- fL
4.Date Well(s)Completed: �—;. Well ID# ft. 1 4 e
It. IL
_ /'D
5a.Well Location: ft. ft
�t G I ft ft.
Facility/Owner Name Facility ID#(if applicable)
It. ft.
Physical Ad City,and Zip 21.REMARKS
�014 ?h 9ff79akll
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: + ( 1%!:I Ii';F ty ��iS1i\il9 Urv1
22.Certification:
(if well field,one lat/long is sufficient) /
N W (t
� Sifted Well Contractor Date
6.Is(are)the well(s): 2 rf ermanent or ❑Temporary By signing this form,I hereby car*that.the well(s)was(were)constructed in accordance
with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.is this a repair to an existing well: ❑Yes or 01V0 copy ofthir record has been provided to the well owner.
If This is a repair,fill out known well construction information and explain the nantre 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 ifnecessary.
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: �a[J (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@10,01 construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+^ 1617 Mail Service Center,Raleigh,NC 27699-1617
]].Borehole diameter: 6.25 (in-) 24b.For Iniection Wells ONLY: in addition 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:
(le.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
(gp m 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: )!
constructed.
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Form GW-I North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013