GW1-2022-04988_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 DESCRIITION
14elt.Conrcrortlztne 2/)n tt. ���fL ^r_
2834-A e. la-s-i ft. o
NC Well Contractor Certification Number 15.OUTER CASING(for multi-6 ed wells)OR LINER if a licable
FROMTO DIA�t E'IER THICKNESS MATERIAL
Kennedy Well Drilling Q ft. I V ft. 6.25 i" I SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(peothermal closed-loop)
7 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#:_ an�- a,�1 Dl l D03 23 ft. fL in.
List all applicable well permits(i.e.County,State, Variance,Iryection,etc)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO it DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public
❑Geothermal(Heating/Cooling Supply) li�esidential Water Supply(single)
ft. ft. in.
❑IndustrialICommercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lrri ation 0 fL 20+ ft- Bentonite Hydrate chips in place
Non-Water Supply Well:
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK(if o plicable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM fL TO ft. MATERIAL EMPLACEMENT METHOD
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,sontrock type,grain size,etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0
ft. [t. / _ _ /a
ft. ft.
4.Date Well(s)Completed: Well ID# d ft. 715--ft. ` �r
5a.Well Location: ft. / s­,rL
tS��G li �!` ee✓t rt. ft.
Facility/Owner N me Facility ID#(if applicable)
ft. ft.
G c r
'cS I GI,"Al ft. ft.
Physical Address,City,and Zip 21 REMARKS ,
/?a4,0�611, V_ 3 qa57f7 e I 2029
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 �(" a9-aO'Za
� Sngnatur f Certified Well Contract4V Date
6.Is(are)the well(s): EgPermanent or ❑Temporary By signing this form,I heehv certify that the ivell(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 R$N. copy of this record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature of the
repair under#21 rernarks section a•on the back ojthis 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 itgeetion or non-watersupply wells ONLY with the same construction,),on can
submit oneform. ''// SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 9� (ft-) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdiJferent(example-3C200'and 2 a 100') construction to the following:
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
If,vater 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
rotary 24a above, also submit a copy of this form within 30 days of completion of w
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 WELLSQNLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: Air 24c.For Water Supply&In_jection 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: SRO L constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013