GW1-2022-04096_Well Construction - GW1_20220418

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WELL CONSTRUCTION RECORD For Internalvse ONLY:
This form can be used for single or multiple wells j
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1.Well Contractor Information:
Kennedy/ 14.WATER ZONES
Billy l FROM TO DESCRIPTION
Well Contractor Name fL & R. M
2834-A R. R.
NC Well Contractor Certification Number 15.OUTER CASING for moN4cased Hells OR LINER if a livable
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling a 6.25 ;In SDR-21 PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: .3 7 qQ 1 ft iz In
List all applicable well permits(i.e.County•State,Yanance,Injection,etc.) R. & in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE TWCXNESS MATERIAL
1t. ft. In.
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) �idential Water Supply(single) It. ft is
❑Industrial/Commercial ❑Residential Water Supply(shared) I8•GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-water Supply Well: O fr. 20+ fL Bentonite Hydrate chips in place
ft. fL
❑Monitoring ❑Recovery
Injection Well: ft. ft.
[]Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK Ka livable
EDRI
TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier, tr.
❑Aquifer Test ❑Stormwatcr Drainage f
❑Experimental Technology ❑Subsidence Control
ING LOG attach additional sheets N neeess
❑Geothermal(Closed Loop) ❑Tracer To D ory rn r eardo sowrock in eta❑Geothermal eatin Coolin Return ❑Other(ex lain under#21 Remarks tL R.4.Date Wells)Completed:3-'7-J-� Well m#Sa.Well Location: fr
D.
Facility/Oar Name Facility ID#(if applicable) J t v
i F(.
Physical Address,City,and Zip 21.REMARKS
Acyre Ia=(3"?1za
County Parcel Identification No.(PIN)
5b.Latitude and Longitude In degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N W 1 13
_ Signature_o2rtrfi�Well Contractor Date
6.Is(are)the well(s): 119—' neat or ❑Temporary By signing this form,I hereby cerrrfy that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 01C.0100 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or MNo copy ofthis record has been provided to the well owner.
If this is a repay,fill out known well construction information and explain the nature ofthe
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: f 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 oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: (fL) 24a. For AU Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3Q200'and 2@10�0� construction to the following:
10.Static water level below top of casing: 30 00 Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Infection 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.-..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
24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test: Air 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: �� constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013