GW1-2022-08000_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:
14.WATER ZONES
Billy Kennedy FROM TO DESCRIPTION
Well Contractor Name aV ft R. �� 4t,
2834-A ft. R.
NC Well Contractor Certification Number 15.OUTER CASING for multi rased•wells OR LINER if a licable
FRORi TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling rt. fL s.25 i" SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loo
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ��y fL R. r
List all applicable well permits(i.e.County,State,Variance,b jectimu,etc.) fL ft. in
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMMETER SLOT SIZE THICKNESS MATERIAL
ft. fL in.
❑Agricultural ❑M�tmicipal/Public
❑Geothermal(Heating/Cooling Supply) 21f.idential Water Supply(single) ft. ft. irr
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑lni ation 0 11- 20+ ft. Bentonite Hydrate chips in place
Non-Water Supply Well:
iL ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
[]Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM I TO I MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
❑Aquifer Test ❑Stormwater Drainage
f4 ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color, ardness willrock tyM grain sin,eta
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) /9ft. ft. •er )j�
It.
4.Date Well(s)Completed: = r�Wc11 ID#
5a.Well Lo
cation:
kP,1l 1'n ft. R.
Facility/Owner Name Facility ID#(if applicable) R• ^p-
Physical Address,City,and Zip 21.REMARKS
Age 06-
County Parcel Identification No.(PIN) Inlvii; 3r :1 is 3zZ-Z-M Unil
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification: Jy
(if well field,one lavlong is sufficient)
N W
Signature Certified Well Contractor l Date
6.Is(are)the well(s): O<Qnent or ❑Temporary By signing this form,I hereby certify that the aseil(s)is-as 6rere)constructed in accordance
with 15.4 NCAC 02C.0100 or 15.4 NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or l 0 copy of this record has been provided to the Weil ossner.
Ifthis is a repair,fill out known well construction information and explain the nature ofthe
repair under#11 remarks section or on the back ofthis form. 23.Site diagram or additional well details:
pp You may use the back of this page to provide additional well site details or well
S.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY ivith the same construction,you can
submit one form. 7 SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 3015 (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-3@200'and 2@I00) construction to the following:
10.Static water level below top of casing: 13�7 (ft.) Division of Water Resources,Information Processing Unit,
lfwater 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
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) 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 hypocholdte Amount: //p 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