GW1-2022-01564_Well Construction - GW1_20220120

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WELL CONSTRUCTION RECORD S<'v s� For internal Use ONLY:
This form can be used for single or multiple wells ,. 1
1.Well Contractor Information: Z
�i lr� i fl`I 14.WATER ZONES
Billy Kennedy Es9 . © FROM TO DESCRIPTION
Well Contractor Name J C° ft• h k 7 �►.,
2834-A �P .':`C-:� e ft. g'5- ft. J
NC Well Contractor Certification Number <i` IS.OUTER CASING for mul' welts OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling ,,;, ' it ( ft. 6.25 id I SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING eothermaI dosed400
�1/r� ^�r� 77 p FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: VQJ 00CM30 ! 1/ k• k is
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
fL ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. is
❑Agricultural ❑M�unicipal/Public
❑Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) ft. ft In.
❑Industrial/Commercial ❑Residential Water Supply(shared) IS.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
01rrigation 0 ft. 20+ fL Bentonite Hydrate chips in place.
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL I 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 streets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardaess,softock type,gnin size,etc.
❑Geothermal(HeatinglCooling Return) ❑Other(explain under#21 Remarks) fL fL it I
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4.Date Well(s)Completed: 12, - Well ID# /p 0.
5,a•.IlWell Location: �A ft, ft46
d /
Facility/Owner Name Facility ID#(if applicable)
-I-3'4 /✓fir-,-/`a.- LAl ft. ft.
Physical Address,City,and Zip 21.REMARKS
l� 7/.6/of!97/G7!(
County Parcel Identi cation 140.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one latflong is sufficient)
N w
SignatuqqfCertified Well Contractor Date
6.Is(are)the well(s): 6ermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an eiisting well: ❑Yes or 21. 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 of the
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 with the same construction,you can
submit one farm. �r SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@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
�g
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: Roiaa 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
Air 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test: 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
33b.Disinfection type: Amount: lD L2L
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Res lurces Revised August 2013
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