GW1-2022-07120_Well Construction - GW1_20220729

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WELL CONSTRUCTION RECORD For internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information: I 1
14.WATER ZONES
Billy Kennedy FROM TO DESCRIPTION
won rnntractar Name
2834-A Z' rt. rt.
NC Well Contractor Certification Number 15.OUTER CASLNG for mul wells OR LINER it s licable
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling 0
it. I If 7 ft. 16.25 In. SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING eother al closed-loop)
� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 5,��t ft. tt. In•
List all applicable well 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
ft. ft. in•
❑Agricultural ❑Municipal/Public
f`' ft.
❑Geothermal (Heating/Cooling Supply) esidential Water SuPP1Y(single) ro•
❑Industrial/Commercial ❑Residential Water Supply(shared) FR GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft- 20+ ft- Bentonite Hydrate chips in place
Non-Water Supply Well:
tr, it.
❑Monitoring ❑Recovery
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)__
FROM TO MA'ITR1AL EMPLACEMENTMEI'HOU
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. g•
❑Aquifer Test ❑Stormwater Drainage
ft. tt.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary
{❑Geothermal(Closed Loop) ❑Tracer I FROM TO DESCRIPTION(color, ry hardness,sailtrock rain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks)] fr. R. O clo
_1 ft. ft. t
4.Date Well(s)Completed:?, Cell ID# ft. --ft. G�
5a.Well Location: ft. ft.
�/r C5t'VIC,YP. ft. it.
Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
'3 7 ✓1e .S/J S
Physical Address,City,an Zip G 21.REMARKS
C k.1-�-w M ,�,r fir. M2
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification: 0G
(if ivellll'fi'eld,one tat/long is sufficient)
N 7Ci l Y60 u-2 7 c✓ W
SignaN v Certified Well Contractor Date
6.is(are)the well(s): ermanent or ❑Temporary By signing this form,i hereby certify that the wells)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 01C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or l3TCo copy of this record has been provided to the it-ell owner.
If this is a repair,fill out known%ve/l construction it formation and explain the nature of the
repair under 421 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 one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: a©� (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdi_ferent(example.3@200'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
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) oZ Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
136.Disinfection type:
granular hypocholrite Amount: LO A)z well construction to the county health department of the county where
constructed.
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Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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