GW1-2022-01562_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
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1.Well Contractor Information:
Billy Kennedy 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name 15 ft. ft '/1't
2834-A ft. f
NC Well Contractor Certification Number 15.OUTER CASING for multi ca ed wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling 0 IL fi- 6.25 SDR-21 PVC
Company Name 16.INNER CASING OR TUBING faeothermaI ctosed400
FROM TO DIAMETER THICKNFSS MATERIAL
2.Well Construction Permit#: MA I -DODwOOC a'4r D• & in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc)
ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
fL g, in.
❑Agricultural ❑MunicipaUPublic
tL ft. in.
❑Geothermal(Heating/Cooling Supply) 211fesidential Water Supply(single)
01ndustrial/Commercial ❑Residential Water Supply(shared) 19.GROUT
FROM I 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: fL ft.
❑Aquifer Recharge []Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier A. 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 color,hardness,soil/rock type,gr2in size,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) fL, S ft. I r i--
4.Date Well(s)Completed: �� Well ID# ft. a It. l�,[f.0v',
It. 1 It. �ro
5a.Well Location: ft. 0�+7 ft.
10At 1 bld'q"aGs CO/t ft. ft.
Facility/Owner Name / Facility ID#(if applicable) ft. ft.
Ag.'Y i1/tJt CL !Oc LOt ft. ft.
Physica�City,and Zip 21.REMARKS
Add 24
County Parcelldentification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one tat/long is sufficient)
N W ,
Signature oCterfified Well Contractor Date
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
t uvth 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: DYes or I/rlo copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature ofthe
repair under#11 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 ivith the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
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##-different(example-3 r@200'and 2@100) 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 (in.) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
24aabove, also submit a copy of{this form within 30 days of completion of well
12.Well construction method: An tot 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) CDV Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form;within 30 days of completion of
]3b,Disinfection type:
granular hypocholrite Amount: R�B_z well construction to the county health department of the county where
constructed.
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Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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