GW1-2022-09098_Well Construction - GW1_20220926

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WELL CONSTRUCTION RECORD For Internal Use ONLY: j
This form can be used for single or multiple wells
1.Well Contractor Information:
Billy Kennedy FROATE TO RZONE5 DESCRIPTION
Well Contractor Name 7,5;-ft. t7 V ft. /tt
2834-A ft ft
NC Well Contractor Certification Number 15.OUTER CASING for TuWk4fed wells OR LINER if a Acable
FROM TO DIAMETER TffiCKNESS MATERIAL
Kennedy Well Drilling 0 ft ft. 16.25 , in. SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loop)
^� nn FROM TO DIAMETER THICKNESS MATERW.
2.Well Construction Permit#: ��t 't� 7�� ft• ft in
List all applicable well permits re.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.
❑Agricultural ❑M�nic[ al/Public
❑Geothermal(Heating/Cooling Supply) [residential Water Supply(single)
❑lndustrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
❑Irri ation 0 fL 20+ ft- Bentonite Hydrate chips in place
Non-Water Supply Well:
% ft.
❑Monitoring ❑Recovery
Injection Well: ft. ft.
[]Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK it applicable)
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier R. ft.
❑Aquifer Test ❑Stormwater Drainage
ft. f4
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM To DESCRIPTION color,hardness6 soiVrock in size etc
❑Geothermal eatin Coolin Return) ❑Other(explain under#21 Remarks ft. IL
R. / ft.
4.Date Well(s)Completed: Q Vl ell ID# ll
0 IL QS ft /' L
5a.Well Location: fL ft.
,�a 17 JS l(,irLYl✓1 L�UGCis ft. ft. i, i,, �rc a-„ s
Facility/Owner Name Facility ID#(if applicable)
ia9 i �,' 1� A;r/•-r / / ft. -
Physical Add s,City,and Zip 21.REMARKS ..
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if wet)field,one latllong is sufficient)
N W - i G'` y'3O olL.o2
Sigoa Certified Well Contractor Date
6.Is(are)the well(s): QPerermanent 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 214 copy of this record has been provided to the well owner.
1fthis is a repair,fill out known well construction information and explain the nature ofthe
repair under#11 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 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-3Q200'and 2@100) construction to the following:
10.Static water level below top of casing: -90 (ft.) Division of Water Resources,Information Processing Unit,
ifwater 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:
(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) J o>Z 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 hypocholrite Amount L�ry y well construction to the county health department of the county where
constructed. i
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013