GW1-2022-07177_Well Construction - GW1_20220729

WELL CONSTRUCTION RECORD For Internal Use ONLY:
77is rune can be used lbr single or multiple wells
1.Well Contractor Information:
Billy Kennedy 14.WATER ZONES i
FROM TO DESCRIPTION
Well Contractor Name ft. 1 ft. 0
vo
2834-A e. e.
NC Well Contractor Certification Number 15.OUTER CASING for roalti-cased wells OR LINER if a livable
FROM TO DIAMETER THICKNESS "ATERIAL
Kennedy Well Drilling 0 ft. 1 3 rt. 16.25 in. SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING eotherroA closed-loop)
3���� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ft, ft. in.
List all applicable well permits(i.e.County,State,Variance,ejection,etc..)
it. R• in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL.
ft. ft. in.
❑Agricultural OM cipal/Public
❑Geothermal(Heating/Cooling Coolin Supply) Residential Water Supply(single)
ft. ft, in.
( g✓ g PP Y) PP Y( g
❑IndustriallCommercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 rt. 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)
FROM I TO MATERIAL I EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
ft. [t.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary
OGeothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION(color,hardness,sollfrock type, rein size,etc
[:]Geothermal(Heating/Cooling Return) 00ther(explain under#21 Remarks) e. 3
4.Date Well(s)Completed: Z„5 -aawell ID#
3 ft. )
5a.Well Location:AA tt. ft.
C,le b ft.
Facility/Owner Name ,,, Facility IDt#(if applicable) ft. ft.
Mrs a�e ctG,d l` fL ft. W V4-
Physical Address,City,and Zip 21.REMARKS
County Parcel Identification No.(PIN) rOCy UDk
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one]at/long is sufficient)
w
35 533.5'8£� N �� ��S7�rJ W �.'A
� Stgnatu •Certified Well Contracto4f Date
6.IS(are)the Well(s): QPermanent or ❑Temporary By signing this form,I hereby certify that the ire/l(s)was(were)constructed in accordance
�_/ frith 15.4 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 3TCO copy of this record has been provided to the nri/owner.
If this is a repair,fill our knoun well construction information and explain the nature of the
repair wider 421 remarks section or on the back ofthis form. 23.Site diagram or additional well details:
/ You may use the back of this page to provide additional well site details or well
&Number of wells constructed: / construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY uhth the same construction.You can
submit one form. SUBMITTAL INSTUCTIONS
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-3@200'and 2©100') construction to the following:
10.Static water level below top of casing: 3" (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 wel
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&Injection Wells:
r/ Also submit one copy of this form within 30 days of completion of
tab.Disinfection type:
granular hypocholrite Amount: b B well construction to the cou I nty health department of the county where
Z I
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013