GW1-2022-01813_Well Construction - GW1_20220207

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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:
Bill Kennedy 14.WATER ZONES ;
Y Y FROM TO DESCItIP7ION
Well Contractor Name a ft. 3O (L
2834-A Sao IL 3a57L Sy �►�
NC Well Contractor Certification Number 15.OUTER CASING for multi cased w OR LINER if a livable
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling Q frq 'L 16.25 ' in I SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loo
- FROM TO I DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft. fL in
List all applicable well permits f.e.County,State,Variance,Injection,etc-)
R 2 in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SUZ THICKNESS MATERIAL
❑Agricultural ❑M�unicipal/Public ft. & is
❑Geothemral(Heating/Cooling Supply) G06sidential Water Supply(single) ft I ft 1O
❑Industrial/Commercial ❑Residential Water Supply(shared) 18•GROUT
FROM I TO MATERIAL _EMPLACEMENT METHOD&AMOUNT
Non Water Supply Well:on 0 ft. 20+ ft- Bentonite Hydrate chips in place
❑Monitoring ❑Recovery ft fL
Injection wen: fL R.
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDIGRAVEL PACK if a livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. R.To MATERIAL I EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. 8
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach additional sheets If necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hArdness,solltrwk Pype,grain eta
❑Geothermal(HeatinglCooling Return ❑other(explain under#21 Remarks D fL rL
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4.Date'Well(s)Completed: •�-.Well ID# ft.
Sa.Well Location: R. ft.
--'���- ft. ft �.1� x i'
Facdi Owner Name Facility ID#(ifapplicable) u `
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LOLL_LLti)�O n / R IL -
Physical Address,City,and Zip
21.REMARKS
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County - Parcel Identification No.(PIN) r� ,; iGvr C rv.:
5b.Latitude and Longitude in degrreeslminutes/seconds or decimal degrees: 22,Certification:
(if well field,one lat/long is sufficient)
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Signature7Attertifred Well Contractor Date
6.Is(are)the well(s): lermenent or ❑Temporary By signing this form,I hereby certify,that the well(s)was(were)constructed in accordance
�' with 1 SA NCAC 02C.0100 or 1 SA NCAC 02C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or 9K0 copy of this record has been provided to the well owner
Ythis 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 with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifjerent(example-3Q200'and 2Q100� construction to the following:
10.Static water level below top of casing: 3 0 (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
rota 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method:rotary 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) (0 Method of test: Air 24e.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: �$o constructed
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Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013