GW1-2022-04112_Well Construction - GW1_20220418

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
ii
1.Well Contractor Information:
Billy Kennedy 14.WATER ZONES B
FROM TO DESCRIPTION
Well Contractor Name ft ft
2834-A rt ft.
NC Well Contractor Certification Number IS.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling 0 ft. i I ft 6.25 i" SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal dosed-loop)
FROM TO DIAMETER TWCKNESS I MATERIAL
2.Well Construction Permit#:z O 17 _b Qoo Q p fL ft in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc) ft ft in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOTSTLE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. R in.
❑Geothermal(Heating/Cooling Supply) QlCsidential Water Supply(single) ft ft in.
❑industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 b- 20+ fL Bentonite Hydrate chips in place
Non-Water Supply Well: ft ft.
❑Monitoring ❑Recovery
Injection Well: ft ft
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK d applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage ft. R.
ft ft
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness soiltrock type,grain size,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft ft t
_ - �I G ft 4.Date Well(s)Completed:3 28 Well ID# JO it 5 ft r
5a.Well Location:
5rt 205 '-
Larrtj Wa, no Willickry):5 ft ft
Facility/Owner Name Facility ID#(if applicable)
Q Q w' �� ft ft. OEM
-r8D tliV015)rle- I<LI• ft ft. rg' . - t_....
Physical Address,City,and Zip
21.REMARKS
R and of ah S(o 110431`1`7
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 al-m-
Signatur4fCertified Well Con or' Date
6.Is(are)the well(s): ermanent or ❑Temporary By signing this form,I 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 e:dsting well: ❑Yes or 42<0 copy ofthis 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 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 if different(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: 35 (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
rotary 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.) Lderground Division of.Water Resource, Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Lo Method of test: Air 24c.For Water Supply&InjectionlWells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type:
granular hypochofdte Amount: I0 loZ well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013