GW1-2022-09096_Well Construction - GW1_20220906

WELL CONSTRUCTION RECORD For Imerna►Use ONLY:
This form can be used for single or multiple wells
GI
1.Well Contractor Information:
Billy Kennedy 1RwATERZONEs
FROM TO DESCRIPTION
Well Contractor Name ft es—rt ,,,
2834-A " ft,
NC Well Contractor Certification Number 15.Ob1'ER CASING for multi-cased we11s OR LINER if a livable
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling 0 rL rt 6.25 In SDR-21 PVC
Company Name ^ tt 16.INNER CASING OR TUBING eothermal closed-too
FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: 02—(,t//�DD N��`` - ft. ft. in.
List all applicable wellpermits(i.e.County,State,Variance,Injection,etc.) fL ft. in.
3.Well Use(check well use): 17.'SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SITE THICKNESS MATERLAL
fG ft. IM
❑Agricultural ❑Municipal/Public
ft. ft. In.
❑Geothermal(Heating/Cooling Supply) 21te'sidential Water Supply(single)
❑Industrial/Commercial ❑Residential Water Supply(shared) 19.GROUT
FROM I TO MATERUAL EMPLACEMENT METHOD&AMOUNT
DItrigation 0 ft. 20+ fL. Bentonite Hydrate chips in place
Non-Water Supply Well: ft. ft.
❑Monitoring ❑Recovery
Injection Well: ft. fL
❑Aquifer Recharge []Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier It. ft.
❑Aquifer Test ❑Stormwater Drainage ft. ft
❑Experimental Technology ❑Subsidence Control 20.DRILLING LOG fattach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM I TO DESCRIPTION color,hardness,wittreck type,grain size etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks ft• ft•
rL as� rL h
4.Date Well(s)Completed: :2co_aa Well ID# tt ft
/b n
5aa..Well Location: ft fL _
ft. ft
Facility/Owner Na4 Facility ID#(if applicable) ft.
7-610 Q"e r G/e4k fL it. "7
Physical Address,City,and Zip 21.REMARKS
County 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 �. � -9 &
i h Certified Well Contractor Date
6.Is(are)the well(s): ermanent 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 affo 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:
1 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 SUBMITTAL INSTUCTIONS
submit one form.
9.Total well depth below land surface: 117J (ft.) 24a. For Ali Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdderent(example-3@200'and 2@100) 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 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:
(Le.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 fom'within 30 days of completion of
13b.Disinfection type:
granular hypocholdte Amount: well construction to the county Health department of the county where
f�ff�
constructed.
Form GW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013