GW1-2022-04989_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 0 ft ft,
2834-A 17iQ
et. -1- ft. 0, ot
NC Well Contractor Certification Number 15.OUTER CASING for multi-ce d wells OR LINER if a licable)
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling 6rt. 7 ft. 6.25 i" SDR-21 PVC
Company Name 16.INNER CASING OR TUBING eother al closed-loop)
7 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: /�� �7 ft. ft. in.
List all applicable ivell permits(i.e.County,State, l'anance,Injection,etc)
ft ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft in.
❑Agricultural ❑Municipal/Public
- ft. ft in.
❑Geothermal(Heating/Cooling Supply) WCesidential Water Supply(single) _
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irrigation 0 rL 20+ rt Bentonite Hydrate chips in place
Non-Water Supply Well:
ft. ft.
[]Monitoring ❑Recovery
Injection Well: fL ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT NIETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft
❑Aquifer Test ❑Stormwater Drainage
ft. it.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG attach additional sheets if necessary)
[]Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soiltrock type,grain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. it.
�1 rt. rt. 9 _
4.Date Well(s)Completed: _d(p`�ioC Well ID#
ft. ft.
5a.//,Well Location: ft.
/V cf k f'f'C64A;Jtty1 ft. ft r
Facility/Owner Name Facility ID#(if applicable)
ft. rt.
Physical Address,City,and Zip 21.REMARKS
�raAofo��ll�. T2!%2 MAY
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees:
22.Certification: �-.,,�--,.,:.,i• +�� '_,..,,.�,ll,I i
(if well field,one lat/long is sufficient) / ? '�jj;y:u.i l"', `
N W
Signature oftertified Well Contractor Date
6.Is(are)the well(s): JR ermanent or ❑Temporary By signing this form,I herebv 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 li ho copy of this record has been provided to the well owner.
Ifthis is a repair,fill out 47iown well construction information and explain tine 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 ifnecessary.
For multiple injection or non-water supphy wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
i
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 ifdifferent(example-3@200'and 2@I00') construction to the following:
10.Static water level below top of casing: r (ft.) Division of Water Resources,Information Processing Unit,
iftvater 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
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&Iniection Wells:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type:
granular hypocholrite Amount: /�n� 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