GW1-2022-04113_Well Construction - GW1_20220418

WELL CONSTRUCTION RECORD For Intemal Use ONLY:
This form can,be used for single or multiple wells
1.Well Contractor Information:
Bill Kenned 14.WATER ZONES
Y Y FROM TO DESCRIPTION
Well Contractor Name 5 u fL toC) % 5
2834-A rt. ft.
NC Well Contractor Certification Number 15.OUTER CASING for T!L1 ased wells OR LINER if a licable
FROM TO DLIMETER THJCKNESS MATERIAL
Kennedy Well Drilling D « .5 rt 16.25 " 1 SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#:;.D2 D -D DDO 1353
rL fr. in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc)
fL ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public fL fL in.
❑Geothermal(Heating/Cooling Supply) F4esidential Water Supply(single) IL ft. in.
❑Industrial/Cormtercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
[]Irrigation 0 fL 20+ fL Bentonite Hydrate chips in place
Non-Water Supply Well: fL ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK tr applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL EMPLACEMENT METHOD
rL e.
❑Aquifer Test ❑Stormwater Drainage
fL ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Trace[ FROM TO DESCRIPTION color,hardness sollfrock ryM gnin size,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) I ft- ft, OLQ
1
1 4.Date Welt(s)Completed: 3 �s 11 Well ID# fL ft. L s� C
rt S ft r c
5a.Well Location: /� fL fL
Jamp-s (^1 so--a rL ft.
Facility/Owner Name Facility ID#(if applicable) rT
f ft.
q 2(D Q R=�be 1 or �_'r9kY-) '} A. `�L ". APR d
$ 202
Physical Address,City,and Zip
1 _
21.REMARKS
ar-Ndo1 753-15�,3
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one W/long is sufficient)
N W 3-25-- 2,
// Signature f Certified Well Contractor Date
6.Is(are)the weil(s): C3Permanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 1 SA NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes Or W<0 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 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: 09q5,
(ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells Cut all depths ifdifferent(example-3@200'and 2@1001 construction to the following:
10.Static water level below top of casing: 130 (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 Infection Wells ONLY: In addition to sending the form to the address in
rotary 24aabove, 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.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service C Inter,Raleigh,NC 27699-1636
139.Yield(gpm) 5 Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type:
granular hypocholrite Amount: ) 0 O Z 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