GW1-2022-09093_Well Construction - GW1_20220926

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WELL.CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Billy Kennedy 14.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name w rL O ft
CrAl
2834-A rt. lY�v rt.
NC Well Contractor Certification Number 15.OUTER CASING formal' ed wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling Q ft. 1 -5-3 ft. 16.25 In SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING(geothermal dosed400
�t
p FROM TO DIAMETER THICKNESS MATERIAL
2.WellConstructionPermit#: aoaa.-ODQOIl09 fL ft is
List all applicable well permits f,e.County,State,Variance,Injection,etc.) .
ft. ft. in.
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft ft. In.
❑Agricultural ❑Mun ipal/Public
❑Geothermal(Heating/Cooling Supply) I esidential Water Supply(single) ft ft ►o•
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 ft. 20+ ft- Bentonite Hydrate chips in place
Non-Water Supply Well:
ft. ft.
❑Monitoring ❑Recovery
Injection Well: fL fL
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage
fL ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessa
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(coror,hardnes soil/rock in s' etc
[]Geothermal(Heating/CoolingReturn) ❑Other(explain under#21 Remarks) ft. ft.
ce
4.Date Well(s)Completed: q 1�-�&ell ID#
ft' ,30v�ft' A&
5a.Well
,.Location: /� ft. fL
t /1 LZJ r1Q/� 6 r /e
Facility/Owner Name Facility ID#(ifapphcable)
ft. ft. SEP ,
Physical Add re ,City,and Zip _
21.REMARKS
County Parcel Identification No.(PIN) D,
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(if well field,one Iattlong is sufficient) // Q
N W 421,
�� Signature ertified Well Contractor Date
6.Is(are)the well(s): BPermanent or ❑Temporary By signing this form,I hereby certrfy that the ivell(s)was(were)constructed in accordance
with 15A NCAC 01C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: Dyes or 2<0 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 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-water supply ivells ONLY tvi h the same cons&uction,you can
submit one form. 7 r SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 30 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdifferent(example-3@200'and 2@I00) construction to the following:
10.Static water level below top of casing: 30 (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 Iniection 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.eager,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) dC 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 1 Z well construction to the county health department of the county where
13b.Disinfection e: Amount: 1
constructed, i
I
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013
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