GW1-2022-09981_Well Construction - GW1_20221104

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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: `
14.WATER ZONES 1
Billy Kernhedy _ FROM TO DESCRIPTION
Well Contractor Name 7.7 ft. R.
2834-A t`
NC Well Contractor Certification Number I5.OUTER CASING for tnuTti cased wells OR LINER Sf a licahle
FROM TO DIAMETER THICKNESS MATERIAL
Kennedy Well Drilling 0 rt. R. 6.25; in SDR-21 I PVC
Company Name 16.INNER CASING OR TUBING eothermal closed-lo )
^� FROM ft.
DIAMETER THICKNESS MATERIAL2.Well Construction Permit#: `��nc 3,1� R. ft, in.
List all applicable well permits ri.e.County,State,Variance,Injection,etc.) ft. In.
ft. �
3.Well Use(check well use): 17.SCREEN
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ft. ft. 1 in.
❑Agricultural ❑MunicS al/Public
[]Geothermal(Heating/Cooling Supply) esidential Water Supply(single) ft, ft, In.
❑Industrial/Commercial ❑Residential Water Supply(shared) 18.GROUT
FROM TO MATERIAL EMPLACEMENT METHOD&AINOUNT
❑hTi anion 0 it. 20+ ft- Bentonite Hydrate chips in place
Non-Water Supply Well:
_ ft. ft. ,
❑Monitoring ❑Recovery
Injection Well: (t. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if applicable)
FROM TO PLACEMENT'METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stormwater Drainage ft. It.
❑Experimental Technology ❑Subsidence Control
20.DRILLING LOG attach additional sheets if necessary
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardnes%soil/rock typc nin size,etc.)
❑Geothermal(Hearin Coolin Return) ❑Other(explain under#21 Remarks) ft. S ft.
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4.Date Well(s)Completed: �)J '-2aell ID€1 ft• _ft
Sa.Well Location: R. ft. _
Facility/ rName Facility IDk(ifappilcable) ft. ft.
Physical Address,City,and Zip 21.REMARKS 5=�+ ftR
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(ifwell field,one lat/long is sufficient)
t /
N W // -- -/K o�'r 52a
Signature enified Well Contractor U Date
6.IS(are)the Well(s): ermanent or ❑Temporary By signing this form,I hereby certify that the rmll(s)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Constuction Standards and that a
7.Is this a repair to an mdsting well: []Yes or 2NO copy ofthis record has been provided to the well owner.
Ifthis is a repair,fill out known well construction information and explain the nature ofthe
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
j 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 oneforrn. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface: 4K (ft,) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths ifdSi ferent(example-3@200'and 1@100) construction to the following: I
10.Static water level below top of casing: '2C (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 fort to the address in
rota 24aabove, also submit a copy!of this form within 30 days of completion of well
12.Well construction method: rotary construction to the following: i
(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&Injeition Wells:
Also submit one copy of this(form within 30 days of completion of
13b.Disinfection type: granular hypocholdte Amount:_ ��� well construction to the county health department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Wafer Resources Revised August 2013
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