GW1-2022-01563_Well Construction - GW1_20220120

WELL CONSTRUCTION RECORD .--°
For Internal Use ONLY:
This form can be used for single or multiple wells t1
1.Well Contractor Information:
14.WATER ZONES
Billy Kennedy . `b .,G`o' FROM TO DESCRIPTION
Well Contractor Name , ���r`` ft. e6 M 2
2834-A NO rt. a.
NC Well Contractor Certification Number e'yk 15.OUTER CASING for mul' wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling rt It. 6.25 in. SDR-21 I PVC
Company Name n 16.INNER CASING OR TUBING eothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: �( R. ft. L in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER StA T 917,E THICKNESS MATERIAL
ft. fL in.
[]Agricultural ❑Municipal/Public
ft. ft.
❑Geothermal(Heating/Cooling Supply) 21(gidential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 9B GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft- 20+ ft- Bentonite Hydrate chips in place
Non-Water Supply Well:
ft. tt.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Grotmdwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier fur ft.
❑Aquifer Test ❑Stormwater Drainage
tG ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING l.oG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color,haMness,soiurock type sim,etc
❑Geothermal(Heating/Cooling Retttm) ❑Other(explain under#21 Remarks) 0
fL 3 iL cl R
1,R
S II Well ID# -3 ft.
4.Date Wells)Completed:
- r rt
5a.Well Location: It- ifEL4
rt.
A%t Q u�q{SS 6)K ft.Facility/Owner Name Facility ID#(if applicable) ft.
Afo,v V t e[0. !0/. ". - a02 ft. ft.
Physical A dress,City,and Zip 21.REMARKS
/1ct•t.a0®loti 77ys'!9/9 Iq
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lattlong is sufficient)
N W
��� Signature of rtified Well Contractor Date
IJl46.Is(are)the well(s): manent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
Wilt 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or IGNo copy of thu 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 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 non-water supply wells ONLY ivith the same construction,you can
submit oneform. �/ SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: r0.7r� (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijjerent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: �(O (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I.Borehole diameter: 6.25 (in-) 24b.For Infection 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: Qt9�a!y 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) S 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
13b,Disinfection type: Amount: Ka 0 L
constructed.
t
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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