GW1-2022-03131_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 DESCRD'770N
Well Contractor Name O R m
2834-A fL fL
NC Well Contractor Certification Number 15.OUTER CASING for multi eased wens OR LINER if a Iicable
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling 0 R frp ft 6.25 In1 SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING eothermal dosed-1
FROM TO DIAMETER I THICKNESS I MATERIAL
2.Well Construction Permit#: 39067 ft. fL in.
List all applicable well permits r e.County,State,Variance,Injection,etc.) fL fL is
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSUZ THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft In.
❑Geothermal(Heating/Cooling Supply) 0Res�idential Water Supply(single) fL fL in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL I EMPLACEMENT METHOD&AMOUNT
❑Irrr anon 0 R. 20+ ft- Bentonite Hydrate chips in place
Non-Water Supply Well:
fL f4
❑Monitoring ❑Recovery
Injection Well: R' fL
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a llebble
I
TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier �
❑Aquifer Test ❑Stormwater Drainage
ft.
❑Experimental Technology ❑Subsidence Control
DRILLING LOG attach additional sheets if neceas
❑Geothemral(Closed Loop) ❑Tracer TO DESCRIPTION color,hardo Wit/rock in da etc.
❑Geothermal eatin Coolin Return ❑Other(explain under#21 Remarks R'
^ ft.4.Date Well(s)Completed: oG-Qa-XZ-Well ID# R.Sa.Well Locations3 9C fLKe Al Z/ ft.
Facility/Owner Name Facility ID#(ifapplicable)60 i 041 I t-�A fLiPhysical Address,City,and Zip . RKS -
Morre, 1t 13 3 3 MAR a 7 202-2-9
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minuies/seconds or decimal degrees: 22.Certification: � +)
(if well field,one lat(long is sufficient) v t. i3t" eUl j
N W �1 0. CU as
Signature o Certified Well Contractor- Date
6.Is(are)the well(s): a rmnanent or ❑Temporary By signing this form,I hereby certijy that the well(s)xns(were)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 BYgo� 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 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
8.Number of wells constructed: construction details. You may also attach additional pages if necessary.
For multiple injection or non-wetersupply wells Oft Yudth the same cons&uc ion,you can
submit oneform. SUBMITTAL INSTUCI'IONS
9.Total well depth below land surface: 3g J/ (fL) 24a. For All Well,, Submit this form within 30 days of completion of well
For multiple wells list all depths iifdijjerent(example-3Qa 200'and 2Qa 100)T construction to the following:
10.Static water level below top of easing: ��j y OL) 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 Injection 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 prate etc.) Division Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) to Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
136.Disinfection type:
granular hypocholrite Amount Mdz well construction to the county health department of the county where
constructed.
r
Form GW-i North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013