GW1-2022-07181_Well Construction - GW1_20220729

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Billy Kennedy 14.'WATERZONEs
FROM TO DESCRIPTION
Well Contractor Name .SOW ` ?2A' ,0 M
2834-A ft. ft.
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NC Well Contractor Certification Number 15.OUTER CASING for multi cased,wells OR LINER if a licable
FRO TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling e. S ft- 6.25 SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING eothermal:closed-loo
2.Well Construction Permit#: ol(�-/ n FROM ft. TO [t. DIAMETER in. THICKNESS MATERIAL
List all applicable well permits(i.e.County, tare,, a�e,lnjection,etc.)
ft. _ ft. is
3.Well Use(check well use): 17rSCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑Muni ' al/Public
❑Geothermal(Heating/Cooling Supply) 2.idential Water Supply(single) ft ft
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation
ft
Non-Water Supply Well: . 20+ ft Bentonite Hydrate chips in place
❑Monitoring ❑Recovery ft. ft.
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19 SAND/GRAVEL PACK ifa licable
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM TO MATERIAL. EMPLACEMENT METHODft, ft.
❑Aquifer Test ❑Stormwater Drainage fL ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color hardness soilfrock type,grain size,etc
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 tL tt.
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4.Date Well(s)Completed: -!aP70 l ID# 30
30 ft. 6-0ft &00 c. —,S
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Sa:Well)Locati : rL rL 6 l, G 1_
,'. � en it I ft.
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Facility/Owner Name Facility ID#(ifapplicable) ft. ft.
, aLOLLb l ft. JUL
Physical Address City,and Zip � 11.REMARKS
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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 a-ac�2a
�� Signature ertified Well Contractor Date
6.Is(are)the well(s): L•?Yermanent or ❑Temporary By signing this form,I.hereby certify that the wells)was(were)constructed in accordance
_� with 15A NCAC 02C.0100 or I5A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or IO1V0 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 ofthe
repair under#21 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
8.Number of wells constructed: f 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: S (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3Q200'and 2@1001 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
II.Borehole diameter: 6.25 (in.) 24b.For Injection Wells ONLY: In addition to sending the form to the address in
rota 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: ry 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) &0 Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
we cons e coup
13b.Disinfection type: Amount: �'
granular hypocholrite well construction to the health department of the where
��Q� I � e county
constructed. JI
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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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