GW1-2022-05896_Well Construction - GW1_20220617

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Bill Kennel 14.WATER ZONES
Y y FROM OM TO DESCRIPTION
Well Contractor Name 1 � IL Ct• �O` �
2834-A i v
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling rt. 1 3 1 ft. 6.25 in SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
`^,�1 a woo
f� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: e�L/'ol_/ w�(_� v ft. Ct. in.
List all applicable well permits(i.e.County,State,Variance,Ejection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Munk 1/Public ft. ft, in.
❑Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hTigation 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)
❑Aquifer Storage and Recovery ❑Salinity Barrier
TO MATERIAL EMPLACEMENT METHOD
er Ct, 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 DESCRIPTION color,hardness,soil/rock type,gmin sirx,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. /0 ft.
4.Date Well(s)Completed:s 19 Well ID# ho ft-
t Ct
ft.
5a.Well Location•:
/l�P:�l1{n 1/��f7� �-�'Ul7�Iyt ft. fL t""�•r...
Facility/Owner Name Facility ID#(if applicable) �-
ft.
Physical Address City,and Zip CJ„
21.REMARKS �
fin, WA A ;
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)
Signature ilgertifed M7e11 Contractor Date
6.Is(are)the well(s): 20ertnarient or ❑Temporary By signing this form,I hereby certify that the wells)u•as(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 ❑No copy of this record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
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 byecfion or non-water supply wells ONLY with the same construction,you can
submit one form. ,✓ SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: � d (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdierent(example-3@200'and 22@1000') construction to the following:
10.Static water level below top of casing GLtJ (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
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) L7® 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: 2'0 7 well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013