GW1-2022-01560_Well Construction - GW1_20220120

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WELL CONSTRUCTION RECORD rorml Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
r`
Kennedy 14.WATERZONES
Billy
y I CJ n FROM TOA DFSCRIPTfON
Well Conbactor Name c� \ � 0 /y
2834-A ,Qr= „`Cj �:O fL fl
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NC Well CmmactorCertificationN®6er 15.OUTER CASING for multi cased weirs OR IdNER da livable
FROM TO DIAMETER TH1CK�i'rSS DIATERtAr.
Kennedy Well Drifting , ' G f '7g " 6.25 in. SDR 21 PVC
Company,Name \� 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMVrM nucl ''ESS MATERIAL
2.Well Construction Permit#: a[Lli�.� - �t/��03) lO fL tt- is
List all applicable wrApermits(1e_Comte.State.Yanance,hrjectian,etc.)
ft. fL in.
3.Well Use(check well use): 17.SCREEN
Water Supply Welk FROM TO D►AMSrER SIATSITE TIDCKNM.SS I MATERIAL
ft. ft.
❑Agricultural ❑M paUPublic
❑Geotbermat(Heating/Cooling Supply) PResideaLal Water Supply(singlc) % 1L in
❑IndustriaUCommercial ❑Residential Water Supply(shared) 1&GROUT
FROM I TO MATERIAL FtHY1.ACEMENT ME1710D&AMOUAT
(31nipation 0 ft- 20+ Bentonite Hydrate chips in place
Non-Water Supply Well: R fL
Monitoring ❑Recovery,
Injection Well: ft ft
❑Aquifer Recharge ❑Choundwater Remediation 19.SAND/GRAVEL PACK d le
FROM TO MATERIAL EMPLACEMPATJfE7HOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage fL fL
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if
❑Geothermal(Closed Loop) ❑Tracer FROM TO DFSCRIPTION(color.hrardaes,soeVrock h s a etc
❑Geothermal(Heating(Coohng gqReturn) ❑Other(explain under#21 Remarks) fL tLaw
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4.Date Wells)Completed: aC- at Well LD# r
rt. ft
5a.Well Location: ' !Z G
fL n
FacifitylOw-nss Namc Facility W#(if applicable) R.
70Sd AA W V 2 a i✓ ft. ft.
Physical Addressj�City,and Zip 21.REMARKS
Ra�cYo � ��35'CaSr�
County Parcel identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat%ng is sufficient)
N W 1.2- �O ;0.1(
� Signatureed Well Contractor v Date _
6.is(are)the wefl(s):LJYern ..IIt or ❑Temporary By signing this foray I hereby certify that the wvWs)was(were)constructed ar accordance
with i5A NCAC 02C.0100 or I5A NCAC 02C_0200[Yell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or BST. copy of this reread has been proWded to the well owner.
lfthis is a repair,fill out brown wrn caysctruction informaion and explain the nature ofthe
repair under#21 remarks section or on the back ofthis 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 note-wvatersupply wells ONL P with the some m afrutlion.you can
submitoneform. SUBMITTAL INSTUC['IONS
9.Total well depth below land surface: �D[.7 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijlerent(example-3 a@200 and 2@a11003 construction to the following
10.Static water Level below top of rasing: L30 (ft) Division of Water Resources,Information Processing Unit,
if water leed is ahme casing use"+' 1617 Mall Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 Gn) 24b.For Iniection Wells ONLY In addition to sending the form to the address in
24a above, also submit a copy of this fort within 30 days of completion of well
12.Well construction method: Ad a construction to the following t
(Le.auger,rotary,cable,direct push,etc.)
Division of Water Resource's,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) otfl Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this fomi within 30 days of completion of
granular hypodtolrite 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 ofWate Resomces Revised August 2013
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