GW1-2022-01735_Well Construction - GW1_20220207

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Billy Kennedy 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft' Q ft. I /tq
2834-A ft. rl
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wells ORLINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL.
Kennedy Well Drilling 0 & ft. 16.25 id SDR-21 I PVC
Company Name I&INNER CASING OR TUBING(geothermal closed-too
p� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#:i9od- DOD O oD W L ft. R- in
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. fL in.
❑Agricultural ❑MunicipaUPublic
--in.-
ft. ft.
❑Geothermal (Heating/Cooling Supply) 2 esidential Water SuPP1Y(single)
❑hldustrial/Commercial ❑Residential Water Supply(shared) I&GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 ft' 20+ ft- Bentonite Hydrate ships in place
Non-Water Supply Well:
ft. fL
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK Cif applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier fL R.
❑Aquifer Test ❑Stormwater Drainage
rt. rt.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG fattath additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soillrock typc size,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) t/ fL �✓ It.
,
ft. 0 ft. s ed x
4.Date Well(s)Completed: 6, Well ID# ft. ft.
gyp'
5a.Well Location: ft. ft.
Eno r r o �46,A/u/f n. rt. P. - f °P 2'
Facility/Owner Name Facility lD#(if applicable)
'0
/30a r.&L4l3: /e�0 /wt ft. ft.
Physical Address,City, d Zip 21.REMARKS
County Parcel Identification No.(PIN)
ntt'v+Tltrliils� i h.I'dt�w k1,J /{1f)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
Signaturda?Certified Well Contra&& Date
6.Is(are)the well(s): Elfermanent or ❑Temporary By signing this form,1 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 existing well: ❑Yes or 91V0 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#21 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 ifnecessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
i
9.Total well depth below land surface• . _(fL)(fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Qa 200'and 2Q/1001 construction to the following:
10.Static water level below top of easing: 3 S (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1.617
i
11.Borehole diameter: 6.25 On-) 24b.For Iniection Wells ONLY: In addition to sending the form to the address in
24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: 1�t7�RN 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) Method of test: Air 24c.For Water Supply&Injection Wells:
St7 Also submit one copy of this form within 30 days of completion of
13b.Disinfection type:
granular hypocholrite Amount: well construction to the county health department of the county where
�d�
- constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013