GW1-2022-01558_Well Construction - GW1_20220120

� I ,
I
I �
4�
WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells o I
I.Well Contractor information: `0, �Q��. \ ' I
Bill Kennedy % •< 14.WATER ZONES
Y y rfr� FROM TO DESCRIPTION
Well Contractor Name C'":,pft ft.
2834-A J {�° j' ft. ft. C
NC Well Contractor Certification Number ;,` �j' 15.OUTER CASING for multi cased wells OR LINER if a licable)
_� FROAI TO DIAMETER THICIOVFSS MATERIAL
Kennedy Well Drilling ft I - fie 6,25 SDR-21 PVC
--- -------
-- — - - ---
Company Name 16.INNER CASING OR TUBING( eothermat dosed-loop)
�/ FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ,�/_, '&/20 a 5r�J ft. ft. in.
List all applicable well permits(i.e.County,State.Variance,hijection,etc.J ft ft in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSI7E THICKNESS MATERIAL
OAgricuhura) ❑MunicipaltPulthc ft. ft. rn
❑Geothermal(Heating/Cooling Supply) �ential Water Supply(single)
ft. ft. in. ----
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 20+ ft- Bentonite Hydrate chips in place
Nolr-Water.Supply Well: ft R
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑GroundwaterRemediation 19.SAND/GRAVELPACK 1'a licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM I TO MATERIAL EMPLACEMENT METHOD
ft. ft.
❑Aquifer Test ❑Stormwater Drainage
tt. R.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(mlor,hardness wiVrock type,grain sim etc
❑Geothermal(Heatingicooling Return) ❑Other(explain under#21 Remarks)
ft. ft.
4.Date Well(s)Completed: �r+�- Well ID# R. —ft.
210
5a.Well Location:
tr. It.
:cJ.e 55 CG ft. ft.
Facility/Owner Name
i7r Facility ID#(ifapplicable) ft. ft.
q� /u�/! 1�I c4a i7&, ft. ft.
Physical Address,City,and Zi 21.REMARKS
1�1'—'U1 l otx 7735--I2ry2S7
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
� Signatu f Ccrtifie`d Well ContractW Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the}cell(s)it-as(here)constructed in accordance
u•uh 15A NCAC 01C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well:. ❑Yes or 01510 copy ojthis record has been provided 10 the well owner.
If thET is a repair,fill out knoiwr well construction information and explain the nanny of the
repair under#21 remarks section or on the back nfthis,form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
S.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 oneform. SUBMITTAL INSTUCTIONS
/
9.Total well depth below land surface: f 04- (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdii ferent(example-3(a100'and 2@100') 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
I
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: l
(i.e.auger,rotary,cable,direct push,etc.) I
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&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: Granular Hypochlorite Amount; / well construction to the countyi health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
I
f _-