GW1-2022-08013_Well Construction - GW1_20220830

WELL CONSTRUCTION RECORD For lnternal Use.ONLY_:
This form can be used for single or multiple wells
1..Welt Contractor Information: I-
0:11..- v,..,....,,.1„ 14.WATER ZONES
vuly \Cis a r��y FROM TO DESCRIPTION.
2834-A ' O R- fit.
b
NC Well Contractor Certification Number I5.OUTER CASING for multi-c 'weT.s OR LINER(if a licable _
FROM TO DIAMETER 'THICKNESS MATERIAL
Kennedy Well Drilling rt ft. 6.25 SDR-21 PVC
Company Name 16.INNER CASING OR TUBING(geothermal closed-loop)
_0�D ._D��D�� FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: V�� ft. ft. in*
List all applicable well permits(i.e.County,Stare,Variance,Injection,etc.) ft, ft. nn
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
fit. ft. in.
❑Agricilltilf'al ❑Municipal/Pubiie
fit. fit. ]n•
❑Geothermal(Heating/Cooling Supply) P fe'esidential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM I TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑hTi ation 0 ft- 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 if applicablel
FROM TO MATERIAL, EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage ft. ft.
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG(attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIP N(colpr,hardness,soil/mck type,gmin size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft- ft.
ft. fL
4.Date Well(s)Completed:O � �0'­Well ID# ft fr.
5a.Well]Location: ft- ft.
Facility/Owner Name Facility ID#(if applicable)
-/ �.lrYlP
� n
Physical Ad dr s,City,and Zip 21.REMARKS AUG -•
`J
County Parcel Identi cationNo.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one laUlong is sufficient)
N W
Signature dgertified Well Contractor Date
6.Is(are)the well(s): ecnent 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 BNo copy ofthis record has been provided to the well owner.
If this is a repair,fill out known well construction information and explain the nature of the
repair under#21 remarks section or on the back of this 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: construction details. You may also attach additional pages if necessary.
For multiple injection or non-writer supply wells ONLY with the same construction,you can SUBMITTAL INSTUCTIONS
submit one form. r� -'
9.Total well-depth below land surface: 0_017 (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:
r
10.Static water level below top of casing: (fit.) 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 Ou-) 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
Air 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test: Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: granular hypocholiite Amount: well construction to the county health department of the county where
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources—Division of Water Resources Revised August 2013