GW1-2022-04930_Well Construction - GW1_20220518

WELL CONSTRUCTION RECORD For Internal 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 rt of ft.
00 rL.
2834-A ft. rt.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells 0R LINER if applicabie
FROM TO DIAMETER THICKNESS I MATERIAL
Kennedy Well Drilling LI) ft. I 3 ft 16.25 in. I SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
p ?f1 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: /D1jC/ ft. ft.
List all applicable well permits(i.e.County,State,Variance,Injection,etc)
ft.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑M icipal/Public ft. rL in.
❑Geothermal(Heating/Cooling Supply) Wesidential Water Supply(single) ft ft. in.
❑Industrial/Commereial ❑Residential Water Supply(shared) 18.GROUT _
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
[Irrigation 0 ft 20+ It- BentoniteHydrate chips in place
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft It.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK it applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft
[]Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRII' ION(color,hardness,soil/rock rain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) D ft. L3 ft. �
ft. tt. ,a
4.Date Well(s)Completed: a� r0i9A -s4 ell ID#
5a.Well Location:
Faci tty/Owner Name Facility ID#(if applicable)
rt rt.
T6 O Id"t /n�te ,d r szek ft. Ift. A ZOE
Physical Address,City,and Zip 21.REMARKS
County Parcel Identification No.(PIN) '=a t ;vw'l
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one lat/long is sufficient)
N W �c�oaZ�
� Signs[ of Certified Well Contractor Date
6.Is(are)the well(s): Permanent 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 EKNo copy ofthis record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature ofthe
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 oneform. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: r� (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if dierent(example-3@200'and 2@I00D construction to the following:
10.Static water level below top of casing: 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: 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.)
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
13b.Disinfection type:
granular hypochofrite Amount: t/d t7 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