GW1-2022-09960_Well Construction - GW1_20221104

WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
14.WATER ZONES
Billy Kennedy FROM TO DESCRIPTION
Well Contractor Name ft. (/�"ft.
2834-A R. D rr•
NC Well Contractor Certification Number 15.OUTER CASING for multi-cased wells OR LINER if a licable
FROM TO DIAMETER THICKNESS MATFnrat.
Kennedy Well Drilling 0 ft- 1 oZ,3 fL 16.25 SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-loo
IO©l7D33D3 FROM TO DIAMETER THICKNESS MATERIAL
2.Well Construction Permit#: ��r' "� it. ft. in.
List all applicable well permits ri.e.County,State,Variance,Injection,etc.)
ft. R, in.
3.Welt Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. in.
❑Agricultural ❑� M�unicipal/Public
❑Geothermal(Heating/Cooling Supply) dlZesidential Water Supply(single) ft ft in.
❑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: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable)
❑Aquifer Storage and Recovery ❑Salinity Barrier FROM ft. ft.To MATERIAL EMPLACEMENTMETHOD
❑Aquifer Test ❑Stormwater Drainage
ft. ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,wiltrock tv a in size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) O ft. 3 ft. rr f
�_4.Date Well(s)Completed: �o6l-Well ID# •�ft. �s'-ft.
5a.Well Location: r ft. ft.
7 ft. ft.
Facility/Owner Name Facility ID#(ifapplicable) ; y
ft. ft. }fir
Iov ,r
Physical Add C'ty,and / 21.REMARKS
022
County Parcel Identification No.(PIN) nim! >,
V.. JX7
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one Iat/Iong is sufficient) p�
N W -yL�� aCJ -o�ao�
� " Signatu f Certificd Well Contracto Date
6.Is(are)the well(s): 1dYermanent 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 Consp-uction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ❑No copy ofthis record has been provided to the well owner.
If this is a repair,fill out(mown well construction information and explain the nature of the
repair under#21 remarks section or on the back ofthisform. 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 welts 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 ij different(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
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.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) / Method of test: Air 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days of completion of
136.Disinfection type: Amount:
granular hypocholrite well constmction to the county health department of the county where
� -o�
constructed,
Form GW-1 North Carolina Department of Environment andNatuml Resources-Division of Water Resources Revised August 2013