GW1-2022-04116_Well Construction - GW1_20220418

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATERZONES
Billy Kennedy i
FROM TO DESCRIPTION
WelI Contractor Name ft. R.
rk
2834-A la0 rt. U ft. I
NC Well Contractor Certification Number 15.OUTER CASING for multi-cas Is OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling 0 tL rt. 6.25 i" SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loo
� /# �i ,FROM TO DIAMETER THICKNESS \tATF.RiAt,
2.Well Construction Permit#: 0I )a( 1/ (�?�_y5,0 ft. ft. in.
Listall applicable well pennits(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 MATERIAI.
k. ft •
❑Agricultural ❑Municipal/Public '
���-- ft. fL i"•
❑Geothemal(Heating/Cooling Supply) CYResidential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑irri ation 0 ft' 20+ ft- Bentonite Hydrate chips in place
Non-Water Supply Well-
ft, ft.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage R R
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)•
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock ty a main six,etc)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. 3 ft.
4.Date Well(s)Completed:V -O-.9,a-Well ID# 0 ft 3 0 ft. �C t
5a.Well Location: tt. .J tr.
J�f C,M t fA+ _se6CT61110,�iY/ ft. ft.
Facility/Owner Name Facility lD#(if applicable) ft, fL
30 63 ;_41
Physical Address,City,and Zip 21.REMARKS M
JL-2 A,1167 Ald4 79 as- y) 9(,
Countv Parcel identification No.(PIN) JL
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: `orsikZrt^I lEj i
(if well field,one[at/long is sufficient)
(/e%7'�-��f_ l��'`��r o20o�a
N W A/.
Signature aCcrtificd Well Contracto ' Date
6.is(are)the wet](s): lzferm.nent or ❑Temporary By signing this fornr,1 hereby certify that the well(s)was(were)constructed in accordance
n•ith 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or coQ0 copy of?his record has been provided to the trefl owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under 021 remarkv 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,roil call
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ffdifferent(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,
I%water level is above casing.use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
I L Borebole 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: p(a� 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
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
granular hypocholrite well construction to the county Health department of the county where
13b.Disinfection type: Amount; ld�l- c constructed. '
Form GW-i North Carolina Department of Environment and Natural Resources-Division of Water,Resources Revised August 2013
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