GW1-2022-03071_Well Construction - GW1_20220307

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 0 ft 'L 1%
2834-A ,- f, p,5-fL
NC Well Contractor Certification Number 15.OUTER CASING for mal wells OR LINER if s licable
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling 0 rL G 6.25 is SDR-21 PVC
Company Name 16.INNER CASING OR TUBING eotherm*I closed-loop)
FROM TO DIAMETER I THICKNESS IMATERIAL
2.Well Construction Permit#: /LID M iL in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.) in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM To DIAMETER SLOT SITE THICKNESS MATERIAL
❑Agricultural ❑Mun p5UPublic R %
❑Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) B in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 1&GROUT
FROM I To _ MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri lion
0 R' 20+ iL Bentonite . Hydrate chips in place
Non-WaterSupply'Well: H ft.
❑Monitoring ❑Recovery
Injection Well: ft. It.
[]Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK rf a livable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM To MATERIAL EMPLACEMENT METHOD
ft. fL
❑Aquifer Test ' ❑Stormwater Drainage
fL fL
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DE oN color,hsrdn soillrock 'n size etc
❑Geothermal(Heating/CoolingReturn ❑Other(explain under#21 Remarks R R
A
4.Date Well(s)Completed: 3'22- Well ID# fL ao ft ! ^
iL O'1 — ` P
Sa.Well Location: u��
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-r/'a ylr6 GR')e- H. ft.
Facility/Owner Name '/ Facility ID#(ifaliplicable)
Lt l l%a i f2iYPolk PC
Ifs ? 4 �1an ! rL rL
Physical Address,City,and Zip
21.REMARKS
CJ%a.l_,'h,c &i MAI
County Parcel Identification No.(PIN)
gi egmes/minutes/seconds or decimal degrees:
Sb.Latitude and Longitude in d egr
(ifwcH field,one lat/long is sufficient) 22.Certification: , e
N W i aoa
-3- A
Signature o ertified Well Contractor Cl Date
6.Is(are)the well(s): permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(svere)constructed in accordance
with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or G< copy of this record has been provided to the well owner.
Ifthis is a repair.fill out known well construction itl/ormation and explain the nature ofthe
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
S.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: d (ft) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3Q200'and 2()a 1001 construction to the following.
10.Static water level below bop of easing: 3 (fL) 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 Infection Wells ONLY:i 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) Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
granular hypocholdte well construction to the county health department of the county where
136.Disinfection type: Amount: •�ODL �
constructed.
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Form GW-1 North Caroler Department of Environment and Natural Resources—Division of Water Resources Revised August 2013
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