GW1-2022-07990_Well Construction - GW1_20220830

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
B 14.\VATERZONES
Billy Kennedy
FROM TO DESCRIPTION
Well Contractor Name oZ wff- ��ft
� .
2834-A it. q R.
NC Well Contractor Certification Number 15.OUTER CASING for mu dwells OR LINER if a licable
FROM TO DIAMETEt: THICKNESS DATERIAL
Kennedy Well Drilling fta ft. 6.25 SDR-21 PVC
Company Name 16.INNER CASING OR TUBING ,e�o¢hermal closed-loop)
Qy FROM TO DIAMEI.In. TIIICKNESS MATERIAL
2.Well Construction Permit#: '. it. [f- in.
List all applicable well permits r.e.County,State,Variance,Injection,etc.)
ft. [L in.
3.Well Use(check well use): 17.SCREEN
W $$supply Wen: FROM TO DIAMETER. SLOT SIZE THICKNESS MATERIAL
ft.
Agricultural ❑Municipal/Public ft. to
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) ft. ft 1n•
❑Industrial/Commercial ❑Residential Water Supply(shared) ls.GROUT _
FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
❑hTi ation 0 tf. 20+ fa Bentonite Hydrate chips in place
Non-Water Supply Well: —
tt. tt.
❑Monitoring []Recovery
Injection Well: ft R.
[]Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if appficable
FROM TO MATERfAI, EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Hamer ft. ft.
❑Aquifer Test ❑Stormwater Drainage ft. I ft.
❑Experimental Technology []Subsidence Control
70.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION color hardn soiItroeh type,gmin size eta
❑Geothermal (Heating/Cooling Return ❑Other(explain under#21 Remarks 0 ft. It. yaie& Q
r��
ft. [t.
4.Date Well(s)Completed: -�-,2Q Well ID#
ft. ft. ,•
Sa,Well Location:
C11e ft. ft.
Facility/O nerName Facility ID#(ifapplicable)
ft. ft.
Physical Address,City,and Zip 21.REMARKS
r:'d� 1L
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one laUlong is sufficient)
N W � -i�-e. fi t� Q1191
� Signa o ert ed Well Contractor 7i Date
6.Is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby 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 ®1 0_ copy ofthis record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature ofthe
repair under#21 remarks section or an the back of thisform. 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 attiach 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: (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths iftli ferent(eyample-3@200'and 22@1100) construction to the following:
10.Static water level below top of casing: X/ (ft.) Division of Water Resources,Information Processing Unit,
Ifwater level is above casing,use"+" 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter- 6.25 (in-) 24b.For Infection 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: rotary 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:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type:
granular hypocholrite Amount: well construction to the county health department of the county where
a
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013