GW1-2021-02150_Well Construction - GW1_20210709

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells E��
1.Well Contractor Information: nn
Billy Kennedy II I� 11 9 2�21 14.WATER ZONES
FROM TO DESCRIPTION
Well CotrtractorName ft.
2834=A iniorm�tion processing91 � ft.
Seotlon
NC Well Contractor Certification Number ®�� 5.OUTER CASING for Tula wells OR LINER ifs licable
FROM TO DIAMETER TTICKIVESS MATERIAL
Kennedy Well Drilling 0ft 0 tt 6.25 iD SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING eothermal closed400
FROM I TO I DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft ft. io
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft in
3.Well Use(check well use): 17.SCREEN
Wateer/gricur Supply Well: FROM To DIAMETER SLOT SIZE THICKNESS MATERIAL
(7ffltural ❑Municipal/Public ft. ft in.
❑Geothermal(HeatingICoolitig Supply) ❑Residential Water Supply(single) It. D' in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
01rri ation 0 n• 20+ ft- Bentonite Hydrate chips in place
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery
Injection Well: R' ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. TO ft MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
ft ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness soWrock tyM grains etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft a ft S `
ft tt
4.Date Wells)Completed:V` I o� Well HW
ft.
5a.Well Location: 919 ft ft
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/j � t
t CI A Le a)Y' ft ft
Facility/Owner Name Facility ID#(if applicable) ft. ft.
4;5:& S f Z ze ✓ -ei Aize P ft ft
Physical Address,City,and Zip 21.REMARKS
A6,41419
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifw,ellll field,one lat/long is sufficient).
J i20ld-CM3 - N 'r2'0JR 3 W f (p- 'coal
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erm Signature ertified d Contractor Date
6.Is(are)the well(s): BPanent or ❑Temporary By signing this form,1 hereby certify that the well(s)was(were)constructed in accordance
with ISA NCAC 01C.0100 or 15A NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 21Vo copy ofthis 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 or not-water supply wells ONLY with the same construction,you can
submit one form / SUBMITTAL INSTUCfIONS
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 ifd((jerent(example-3@200'and 1Qa 100) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
/fwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Infection 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
�f 12.Well construction method: L u J, 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&InlecdonWells:
Also submit one copy of this form within 30 days of completion of
granular hypoehdidte well construction to the county health department of the county where
13b.Disinfection type: Amount:
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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