GW1-2022-04115_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
1.Well Contractor Information:
Billy Kennedy 14.WATER ZONES
FROM TO DESCRIPTION
Je1lContractorName tt it nif7
2834-A rt ,tic. 06�
NC Well Contractor Certification Number 15.OUTER CASING for multi-case ells OR LINER if a lk!a le
FROM TO DIAM ER THICKNESS I MATERIAL
Kennedy Well Drilling 04 ft' 33.ft 6.25 in• SDR-21 PVC
Company Name 16.INNER CASING OR TUBING eothermal dosed-loo
�1 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: it. ft.
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 ❑Municipal/Public it ft in
❑Geotherm l�al(Heating/Cooling Supply) idential Water Supply(single) ft' ft. in.
❑lndustrial/Commercial ❑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: ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM it ft.TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color,hardness soiltrock qpe,grain size,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) I ft oZ ft*
ft. n/ ft. to
4.Date Well(s)Completed: 3-/6`01Z Well ID# ft fL0
a.Well Location: ft ft
ft ft
Facility/Owner Nami Facility ID#(ifapplicable) ft ft f.
`TES 52'O wt -A,-yes ft ft. APR 18 202?
Physical Address,City,and Zip
21.REMARKS
lal•rr•
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 nil- /L 3"
� Signatu f Ce ed Well Con-GO-Jr- Date
6.Is(are)the well(s): 21ermanent or ❑Temporary By signing this form,I hereby certify that the well(s)was(were)constructed in accordance
�tv� 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 IQo 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 ifnecessary.
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: _(fL) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths 1fdijferent(example-3@200'and 1@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
11.Borehole diameter: 6.25 (in.) 24b.For Injection Wells ONLY: 1n 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: C.
.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
r'OR 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:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type:
granular hypocholrite Amount: C 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