GW1-2022-08012_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:
Billy Kennedy FROM
ZONES DESCRIPTION
Well Contractor Name Q it 2
2834-A rt. R.
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased welds OR LINER if a livable
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling ft. I it 6.25 1n SDR-21 PVC
Company Name 16.INNER CASING OR TUBING eotbermal closed-loop)
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: � ���a®Z ft. ft. in.
List all applicable well permits(i.e.Count),,State,Variance,Injection,etc.)
(t. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE TIDCIMES.S MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. is
❑Geothermal(Heating/Cooling Supply) 9fresidential Water Supply(single) f' rG in.
01ndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hri ation 0 H- 20+ ft. Bentonite Hydrate chips in place
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery -
Injection Well: ft ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK ifa livable
FROM TO 3ATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery []Salinity Barrier ft. ft
❑Aquifer Test ❑Stormwater Drainage
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIP ON color bardne wiUrock e. min sim etc
❑Geothermal eating/Cooling Return ❑Other(explain under#21 Remarks) ft. 3 it
�_� ft. ft. I _
4.Date Well(s)Completed: 1))QWell ID# f
wft. ft.
5a.Well Location: ft. ft.
T,��b' �ELeD'le'Ci`l ft. ft. F • ':
Facility/Owner Name Facility ID#(if applicable)
f4 ft.
Ca. s 5&Aef1 ^Q/M a _ iL ft. 7 _
Phyyssical Address,City,and
-Zip �•���/t�p� ,r �./ 21.REMARKS
P�ar��io1ir�, /r/J�' rJ.C1�J f��S Ir1i��i'rf:::<:.•! t �,•_=:•.,:_. �,�t
County T 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 U � - �C
SignaturaoCedifiediVell Conhactor _ Date
6.Is(are)the well(s): gwrriinent or ❑Temporary By signing this form,I hereby certify that nk well(s)was(here)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 ff<o 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 021 remarks section or on the back ofthls form. 23.Site diagram or additional well details:
r 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: (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@I00) 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 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: 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) O Method of test: Air 24c•For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
granular hypocholdte well construction to the county health department of the county where
13b.Disinfection type: Amount., ��
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013