GW1-2022-01557_Well Construction - GW1_20220120

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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:
n ..WATER ZONES
Billy Kennedy 40 c oM TO DESCRIPTION
Well Contractor Name 6 � O— ft ft.
2834-A 2.5- ft. 130 a.
a .O
ly a ;.)L� rl. 15.OUTER CASING for ma wells OR LINER if a lieable
NC Well Contractor Certification Number J ^,`� FROM TO DIAMETER THICIINFSS MATERIAf.
Kennedy Well Drilling � �� 0 ft a• 6.25 id SDR-21 PVC
Company Name 0, 1&INNER CASING OR TUBING(geothermal dosed-loop)
XN FROM TO DIAMETER THICKNESS MATF.RiAL
2.Well Construction Permit#:AW —67000 Z 737 7 ft tt• 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
tt, ft in.
❑Agricultural OM u ipal/Public
❑Geothermal(Heating/Cooling Supply) P1Residential Water Supply(single) fL ft. in.
❑lndustrial/Commercial ❑Residential Water Supply(shared) FR GROUT
FROM 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 fc.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAYEI PACK(if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft ft.
❑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 teolor,hardness,soll/rock type sbA Ma
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft ft
ft.
4.Date Well(s)Completed: 02� 019-D-I Well ID# ft. OW ft
5a.Well Location: ft. ft.
ln5`.e,1QA e ft. ft.
Facicihtyy//OvAcr Name �/ Facility lD#(if applicable) ft. ft.
47kq'rgr, Yoek /Cn/ ft ft
Physical Address City/,and Z 21.REMARKS
In 77742-1 �le10
County T` Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one latllong is sufficient)
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N W a� �
� Signs of Certified Well ContracIV Date
By signing this form,I hereby certify that the well(s)was(were)constructed in accordance 6.IS(are)the weil(S): l3Permanent or ❑Temporary
�' 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 91V0 copy of this record has been provided to the well owner.
If this is a repair,fill our 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 coy?
SUBMITTAL INSTUCTIONS
submit one form.
9.Total well depth below land surface: (fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2Q100') construction to the following:
10.Static water level below top of casing: (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 On.) 24b.For Iniection Wells ONLY hi 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: R / et/ 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 276994636
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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 hypocholrite well construction to the county health department of the county where
136.Disinfectiontype: Amount: �t3� constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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