GW1-2022-04987_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:
Billy Kennedy 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name rO ft. ft. O/
2834-A rt.
NC Well Contractor Certification Number 15.OUTER CASING(for multi- sed wells)OR LINER if a licable)
FROM TO DLISIETER THICKNESS MATERIAL
Kennedy Well Drilling 0 ft. rt. 1 6.25 i SDR-21 PVC
Company Name 16.INNER CASING OR TUBIIVG eothernal closed-loop)
2.Well Construction Permit#: aO/�2a_ FROM TO DIAMETER THICKNESS MATERIAL
�n���_ ft. ft. in.
List all applicable ivell 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 ❑Muni ipal/Public ft. ft.
❑Geothermal(Heating/Cooling Supply) QWeesidential Water Supply(single)
ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well:
❑hri anon 0 n 20+ fL Bentonite Hydrate chips in place
it. ft.
❑Monitoring _ ❑Recovery
Injection Well:
DAquiferRecharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifa dicable)
❑ FROM TO Aquifer Storage and Recovery ❑Salinity Barrier rL ft 31,1TERLIL EMPLACEMENT METHOD
❑Aquifer Test ❑StormwaterDrainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soilfrock type,gmin size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) D ft. / ft. /
0
4.Date Well(s)Completed: s _ ��Well ID# fr. ft.
-
3
5a.Well Location: ft. ft.
���, � l� Ll_7.l1•Q...,�i� rr. rr.
Facilit .Owner Name Facility ID#(if applicable) ft. $.
6,Ll 3 1 F_a _ti 1. 5 a r I/l/'
Physical Address,City,and Zip
21.REMARKS
/fah d&gZd_®�
County Parcel Identification No.(PIN) MAY -
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one]at/long is sufficient) C"•`ra ? (;;I;'d
)` W �.t..n'..,�'i tIY J'.,I itvt 11'J�.IL_'1•J �✓ .[fJ012
��-'' Signature o ertified ell Contractor Date
6.Is(are)the well(s): epl;rmanent or ❑Temporary
By signing this form,J hereby certifv that the well(s)was(were)constructed in accordance
with 15,4 NCAC 02C.0100 or 15A NCAC 02C.0200 Mell Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or RN-0- copy oj'this record has been provided to the well owner.
If this is a repair,fill out known ivell construction information and explain the nature of the
repair under#21 remarks section or on the back oj'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 irlieclion or non-watersupply wells OMY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIOIV_S
9.Total well depth below land surface: �,� (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well_.
For multiple wells list all depths ifdierent(example-3C200'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
11.Borehole diameter: 6.25 (in.) 24b.For Iniection 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 w�el
12.Well construction method: rotary 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 hypocholrite Amount: well construction to the county health department of the county where
constructed.
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