GW1-2022-04114_Well Construction - GW1_20220418

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
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1.Well Contractor Information:
Bill Kenned 14.WATER ZONES
Y Y FROM TO DESCRIPTION
Well Contractor Name it. O fL i ,
2834-A tL rt. t
NC Well Contractor Certification Number 15.OUTER CASING for multi cased wens OR LINER if s licable
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling p ft. 61 ft. 6.25 SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: cQM '0000 03 1.3 ft. fL 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 SLOT SIZE THICKNESS MATERIAL
❑Agricultural OMunicipal/Public ft. ft _LLLm.
❑Geothermal(Ilcating/Cooling Supply) 9Kesidential Water Supply(single) ft. ft in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri ation 0 rt. 20+ lt. Bentonite Hydrate chips in place
Non-Water Supply Well: fL ft.
❑Monitoring ❑Recovery
Injection Well: fL
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barri FROM TO MATERIAL EMPLACEMENT METHODer ft. fL
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness,soittrock in dze,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
0 ft. � fL
4.Date Weil(s)Completed: 3-al-as weu ID# ft. fL 6r ,� �S>l•
5a.Well Location:
' ft 3 oy It. c
6"/ i 0,2 he n A ft. ft.
Facility/Owner 14ame Facility ID#(ifapplicable)
_ ft. ft.
1 Y57 /Q/ Gro_ss •V 1a.3s / /�N/GL� ft. ft.
Physical Addrrs,City,and Zip
21.REMARKS APR
AOA010144 �7aa�3�syL
County Parcel Identification No.(PIN)
5b.Latitude and Longitude
in iendegrees/minutes/seconds or decimal degrees: 22•Certification:
( g )
N w
���� Signature&�fied Well Contractor Date
6.Is(are)the well(s): 09f 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 existing well: ❑Yes or 9K0 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
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 oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: I ML (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdijferent(example-3@200'and 2@100) construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If water level is above casing,use"+" 1617 Mail Service;Center,Raleigh,NC 27699-1617
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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.) 1
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:
02.
Also submit one copy of this form within 30 days of completion of
136.Disinfection type: Amount:
granular hypo cholrite /t well construction to the county health department of the county where
9 ns
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013