GW1-2021-00760_Well Construction - GW1_20211208

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells f
1.Well Contractor Information: 11
Bill Kennedy 14.WATER ZONES
Y J FROM TO I DESCRIPTION
Well Contractor Name ft. 11
ft.
2834-A ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING Tor multi cased wells OR LINER if able
FROM TO DIAMETER THICKNESS a lic MATERIAL
Kennedy Well Drilling Q ft- I pot.ft 6.25 1O SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed400
A FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: dl/� '000U )4139 ft. lit. 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
fL ft is
❑Agricultural ❑Munict.al/Public
❑Geothermal(Heating/Cooling Supply) esidentiat Water Supply(single) ft ft
❑Industrial/Commerciai ❑Residential Water Supply(shared) 18•GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lyd ation 0 fL 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 if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrie FROM [t. TO I
ft. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESC ON color,hsrdoes soWrock type, eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 fL ft.
ft. /_ ft. Lt! $ 15
4.Date Weil(s)Completed: _��Well ID# 19, 44/
5a.Well Location:/ ft. fftt .1{e
gy"t .
S ft. ft.
Facility/Owner Name T- Facility ID#(if applicable) t
�Gs 7 Alt-- du,�4 1-3 !1 ft. ft.
Physical Address,City,and Zip l
21.REMARKS
761'y116?`
County Parcel Identification No.(PIN)
iJ�...i
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N w ld(��
� Signature��"`5ed Well Contractor Date
2 6.Is(are)the well(s): ermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)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 211-0 copy of this record has been provided to the well owner.
If this is a repair,Jill 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 or non-water supply wells ONLY with the same construction,you can
submit one form. �/ SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: T� (R.) 24a. For All Wells: Submit this form within 30 days of completion of welt
For multiple wells list all depths ifdifferent(example-3(a)200'and 2Q1001 construction to the following:
10.Static water level below top of casing: 2 1) (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+' 1617 Mail Service Center,Raleigh,NC 27699-1617
IL 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) 1 J Method of test: Alf 24c.For Water Supply&InjectionWells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Granular Hypochlorite Amount: �Q� well construction to the county health department of the county where
constructed.
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Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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